😁 Orthodontic Assessment

Orthodontic (Invisalign) Assessment Template (Heidi-Compatible) --- Patient Info & Chief Complaint **Dentist:** [Dentist name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Nurse:** [Nurse name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **MH Checked and Updated:** [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **RFA (Reason for Attendance):** - Orthodontic assessment / Invisalign consultation **Chief Concerns:** - Patient’s description: [Chief concern description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Clinical goals: [Patient goals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Previous Orthodontic Treatment:** [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- Extraoral Exam **TMJ:** - Clicking / Crepitus / Popping / Grating / Deviation: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - TMJ Pain: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - TMJ Manipulation: [Easy / Hard] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Range of Opening: [Measurement] mm (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **MoM / Lymph Nodes:** [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Skeletal Assessment:** - AP Relationship (Skeletal base): [Class I / II / III] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Vertical (FMPA): [Average / Increased / Decreased] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Facial Thirds Even: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Transverse: [Symmetrical / Deviation to Left / Right] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Smile Aesthetics:** - Incisal show at rest: [Value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Incisal show on smiling: [Value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Smile arc parallelism: [Finding] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Buccal Corridors: [Wide / Narrow] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Midline coincident with facial midline: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Upper & Lower Midlines coincident: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Lip form: [Thick / Thin] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Lip Competency: [Competent / Incompetent] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Lip Catch: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Nasolabial Angle: [Normal / Acute / Obtuse] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- Intraoral Exam **Oral Hygiene:** [Excellent / Fair / Poor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Biotype:** [Thin / Normal / Thick] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **BPE:** [Value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Soft Tissues:** [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Tooth Quality / Caries / Perio / Restorations / Wear / Trauma:** [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Upper Arch:** - Crowding: [Mild / Moderate / Severe] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Spacing: [Mild / Moderate / Severe] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Rotations / Malalignment: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Labial Segment Inclination: [Proclined / Retroclined / Upright] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Arch Shape: [Narrow / Wide / Symmetrical / Asymmetrical] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Lower Arch:** - Crowding: [Mild / Moderate / Severe] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Spacing: [Mild / Moderate / Severe] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Rotations / Malalignment: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Labial Segment Inclination: [Proclined / Retroclined / Upright] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Arch Shape: [Narrow / Wide / Symmetrical / Asymmetrical] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- Occlusal Scheme **Incisal Relationship:** [Class I / II div 1 / II div 2 / III] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Molar Relationship:** - RHS: [I / II / III] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - LHS: [I / II / III] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Canine Relationship:** - RHS: [I / II / III] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - LHS: [I / II / III] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Overjet:** [Measurement] mm (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Overbite:** [Percentage] % (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Complete / Incomplete / Tooth / Soft Tissue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Crossbites:** [Anterior / Posterior – Buccal / Lingual] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Teeth Involved:** [List] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Lateral Excursions:** - Right: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Left: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Protrusive Excursion:** [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- Radiographic & Photo Records **Radiographs:** [PA / OPG / BW / CBCT] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Date: [Date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Justification: [Reason] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Grade: [A / N] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Radiographic Findings: [Radiopacities / Radiolucencies / Bone levels / Root morphology / Others] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Photos Taken:** [EO / IO] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- Diagnoses & Problem List **Diagnosis:** [Diagnosis details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Problem List (with plan to correct / accept / improve):** 1. [Problem 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 2. [Problem 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 3. [Problem 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 4. [Problem 4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Treatment Goals:** - Aesthetic (face, smile, soft tissue): [Goal] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Occlusion (static and functional): [Goal] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Structure (dentition and restorations): [Goal] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Biology (periodontium, roots, bone): [Goal] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- Discussion & Treatment Plan **Options Discussed:** 1. Referral to Orthodontic Specialist – comprehensive treatment, possible skeletal/facial changes 2. GDP-led cosmetic alignment (3-3 focus): a. Invisalign – Clear removable aligners (24/7 wear), IPR and attachments may be used b. Fixed Appliances – Clear brackets, faster movements, discreet **Patient Decision / Preferred Option:** [Decision] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Discussion Summary:** [Expectations / Risks / Timelines / Costs / Whitening or Bonding add-ons] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Treatment Plan:** - Records Appointment: [Yes / No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Consent / Photos / Scans completed: [Findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Referral Made: [Details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **4STP Notes:** 1. Presenting Complaint: [Detail] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 2. Upper Anterior Reference Point: [Detail] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 3. Upper Expansion Point: [Detail] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 4. Final Overjet & Overbite Goals: [Detail] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Next Steps / Follow-Up:** [Detail] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) --- (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)