Patient Motivation For Treatment Form

Patient Motivation for Treatment Form

Patiens often request changes in their bites or faces and relief form pain or discomfort. Please help us understand your problem by checking the following information. Please be specific (select the words more, less,forward, backward, longer, shorter, etc.):

The Teeth

If your teeth could be changed, how would you like them to change?

make the upper front teeth

make the line of the upper teeth more level

Other

The Face

If your facial appearance could be changed, what would you change?

get rid of sag under lower jaw

move chin

move chin to center it

make the profile of my nose

move the area under my eyes

make my cheekbones

make my lips when my teeth are touching

make my lips not touch and roll out when my teeth are touching

reduce the strain when I close my lips

make my face more

reduce my lower jaw behind my mouth

Other

Realizing that successful treatment greatly depends upon the patients complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment? I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical / dental status, I will so inform this practice.

Signature of Patient

date

MEDICAL HISTORY UPDATES OR CHANGES, DATES, COMMENTS

Location

or

Be sure to bring the printed form with you on your first visit.