Orthodontic Initial Consultation Note

Date: [Date]   Patient Name: [Patient name]   DOB: [DOB]   Provider: [Provider name, credentials]

Referral Source: [Referring clinician/office or self-referred] (Only include if applicable)

Accompanying Adult: [Name], [Relationship]   History Provided By: [patient / parent / both] (Include for minor patients)

Chief Concern

[Primary concern(s) in patient/parent words] (List multiple concerns in patient-priority order. If patient cannot articulate a concern, document referral reason or parent concern and note this.)

History

History of Present Concern: [Brief description of concern including onset, progression, and functional symptoms such as chewing difficulty, speech concerns, jaw pain/clicking, or bite trauma] [Prior opinions from other providers if relevant] (Do not infer symptoms from exam findings alone.)

Medical History: [Significant conditions affecting orthodontic care such as bleeding disorders, immunosuppression, diabetes, bone metabolism disorders, or cardiac history] [Current medications] Allergies: [NKDA / Allergies reviewed—none reported / Allergy status unknown—unable to confirm today / specific allergies] (Allergy status must always be explicitly documented.)

Dental/Orthodontic History: [Current general dentist] [Caries and periodontal history] [Trauma/endodontic history] [Prior orthodontic treatment including phase I, aligners, expanders, retainers] [Habits such as thumb sucking, mouth breathing, bruxism] [Airway/sleep concerns if reported—note as screening only] (For children/adolescents, include growth status indicators and relevant family history affecting treatment timing when applicable.)

Examination

Extraoral and Facial Analysis

[Facial symmetry] [Profile: straight / convex / concave] [Vertical facial pattern] [Lip competence at rest] [Smile esthetics] (Do not assign cephalometric diagnoses without records.)

TMJ and Musculature

Symptoms: [Patient-reported joint sounds, pain, functional limitations] (Include if reported.)

Exam Findings: [Joint sounds] [Pain with palpation] [Range of motion] [Deviation on opening]

Intraoral and Oral Health

[Soft tissue abnormalities] [Oral hygiene status] [Periodontal screening assessment] [Caries or restorative concerns affecting appliance feasibility] (If significant active disease is present, document impact on orthodontic readiness.)

Dentition Status

[Dentition stage: primary / mixed / permanent] [Clinically missing teeth] [Retained primary teeth] [Ectopic eruption concerns] [Third molar status if known]

Occlusion

• Sagittal: [Molar relationship R/L with Angle classification] [Canine relationship R/L] [Overjet in mm]
• Vertical: [Overbite in % or mm] [Deep bite / open bite if present] [Gingival trauma if present]
• Transverse: [Posterior crossbite R/L, unilateral / bilateral] [Scissor bite] [Dental midlines relative to facial midline with deviation in mm]
• Alignment: [Crowding or spacing by arch in mm or mild / moderate / severe] [Rotations] [Arch coordination]
• Functional: [CO-CR discrepancy if assessed] [Functional shift with description] [Guidance pattern if examined]

(Use consistent measurement units. If not measured, use qualitative descriptors and note "not measured"—do not estimate.)

Diagnostic Records

External Records Reviewed: [Type, date, source, adequacy, key orthodontic findings] (Include if available.)

Records Obtained Today: [Type obtained such as photos, intraoral scan, radiographs] [Clinical indication] [Consent documented]

Radiographic Interpretation: [Eruption patterns] [Missing or supernumerary teeth] [Root morphology concerns] [Pathology requiring referral] [Periodontal bone levels] [Incidental findings with follow-up plan] (Include if radiographs obtained or reviewed.)

Assessment

Diagnostic Summary

[Facial/soft tissue pattern] [Skeletal tendency: Class I / II / III, vertical pattern] [Dental findings: Angle classification, alignment issues, bite relationships] [Functional considerations] [Oral health readiness] (Label as preliminary if complete records pending.)

Problem List

• [Problem name; laterality if applicable; severity: mild / moderate / severe with supporting evidence; status: confirmed / suspected pending records]
• [Additional problems in order of severity/priority]

Plan

Today: [Examination completed] [Records obtained with consent] [Counseling provided] [Referrals initiated]

Records Needed: [Specific items required: standard photos, panoramic radiograph, lateral cephalogram, intraoral scan, periodontal evaluation, CBCT if indicated] [Rationale] [To be obtained today / at scheduled records appointment] (If patient declines, document informed refusal and diagnostic limitations.)

Preliminary Treatment Discussion: [Options discussed: observation / interceptive treatment / comprehensive treatment / extraction vs non-extraction / surgical pathway] [Patient preferences regarding appliance type or timing] (Note final recommendations contingent on complete diagnostic records.)

Referrals: [Referral and reason: general dentist / periodontist / oral surgeon / ENT or sleep medicine / speech therapy] (Include if applicable.)

Follow-up: [Next visit type: records appointment / treatment planning consultation / monitoring recall] [Target timeframe]