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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? 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? 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
