Download Patient Questionnaire

Patient Name:
Date:
Are you interested in: (Please indicate all that apply):
Information
Treatment at this time
Clarification of previously recieved information
If your child’s teeth were to be changed, how would you like them changed?
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Upper teeth
Forward/ Backward
Lower teeth
Forward/ Backward
Upper teeth because gums show too much
Close spaces
Upper/ Lower
Straighten crowded teeth
Upper/ Lower
Improve the appearance of chipped/cracked/stained/dark/pointed teeth
Do you realise that growth has a strong influence on the success of orthodontic treatment?
Yes____________ No________________
Is it likely that your son or daughter will be an early or a late maturer?
Early_________
Late_________________
How tall do you think your child will be when they are fully grown? ____ft_________inches
Are you aware that orthodontic treatment can sometimes alter facial appearance?
Yes____________ No____________
If any features of the face could be changed, what would you like to see?
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Upper lip
Lower lip
Upper jaw
Chin
Nose
Forwards/ Backwards
Forwards/Backwards
Forwards/Backwards
Larger/Smaller
Larger/Smaller/Different shape
Would you prefer if facial appearance was not discussed in front of your child?
Yes__________ No___________
Is there any significant family history of jaw or teeth problems?
Are you interested in improving the appearance of the teeth at this time, even if more treatment
will be needed later?
Yes___________ No_____________
Signature
Relationship to the patient