8/16/2019 CCO Patient Diagnostic Sheet v6

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CCO Patient Diagnostic Sheet

Patient: __________________ Age: ______ Referring Doctor: __________________ 

CC: __________________________________________________________________ 

Goals for Treatment: _____________________________________________________ 

Obstacles to Ideal Treatment: _______________________________________________ 

History of Concerns: _____________________________________________________ 

 _____________________________________________________________________ 

 _____________________________________________________________________ 

Clinical TMJ Data

Right Left

Opening Click 

Closing Click 

Crepitation

Deviation mm mm

Max Opening mm

Functional Shift mm R L A

Date: ________________ 

Chart: ________________ 

Periodontal Data

Frenum Max Labial Mand Labial Lingual Buccal

Biotype Normal Thin Thick  

Recession None Localized: _________ Generalized

Absent Present

Visible Plaque Absent Present

Fremitus Absent Present

Occlusal Trauma None Anterior Posterior

Lower Archform Normal Constricted

Spacing/Crowding None Mild Moderate Severe

Upper Archform Normal Constricted

Spacing/Crowding None Mild Moderate Severe

Overbite Ideal Shallow Open Deep

Overjet Ideal Mild Moderate Severe Negative

Crossbite None Unilateral Bilateral Anterior Skeletal

Molar Class 1 II div. I II div. II II sub R II sub L III

Wear Facets None Anterior Posterior

Excursion Right Canine Posterior GF Anterior GF NW Interferences

Excurstion Left Canine Posterior GF Anterior GF NW Interferences

Protrusive Anterior Guidance Balancing Interferences

Dental Data

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Muscular TMJ Data

Palpation (1-10) Right Left

Temporalis

Masseter

Submandibular

Pterygoid

Occipital

SCM

Trapezius

Intracapsular

Resistance Yes No

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Ma illa Man ible

Incisor Inclination (X2)

Crowding/Spacing

Maxillary Expansion

Dental Expansion

Curve of Spee

Tooth/Size Discrepancy

Unresolved Space Requirement

Extraction

Distalization/Mesialization (X2)

IPR

Final Space Requirement

Space Requirement

Transverse Diagnosis

Sagittal Diagnosis (CR) Vertical Diagnosis (CR)

Radiographic TMJ Data

Skeletal  CBCT CAC   Dental  Meas red Ideal

Maxilla MGJ-MGJ

Mandible FA-FA

Difference CF-CF

Ideal 5 5 P-P

 FA-FA

Required

Skeletal I / II / III

Dental I / II / III

Maxilla

Mandible

Overjet mm

Skeletal Open Normal Deep

Dental Open Normal Deep

Maxilla

Mandible

Overbite mm

Right Left

Past Remodeling

Altered Joint Space

Subcortical Cyst

Erosion

Edema

Orthodontic Plan Retention Strategy Restorative Plan

  Anchorage: Min Mod Max Maxilla:

  Anchorage: Min Mod Max Mandible:

Treatment Alerts Surgical Plan

Periodontal Plan Other Disciplines

Patient: ___________________________ Chart: ________________ Page 2

Airway Data

Snoring

Brux / Clench

AM Headache

Tires Easily

Asthma/Allergies

Tonsils

Apnea

Cross Section mm2

Archform

Template

Mandible S M L Custom

Maxilla S M L Custom