Orthodontic Treatment Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Orthodontist Note

Patient Identification: [Patient name, age, gender, presenting for orthodontic evaluation/treatment]

Chief Complaint:
[Brief statement of patient's main concern or reason for visit]

History of Present Illness:
[Description of dental/orthodontic concerns, onset, progression, previous treatments, and any associated symptoms]

Dental History:
(hyphenated list)
- [Previous dental treatments]
- [History of extractions]
- [History of trauma]
- [Previous orthodontic treatment]
- [Oral hygiene practices]

Medical History:
(hyphenated list)
- [Relevant medical conditions]
- [Current medications]
- [Allergies]

Family History:
(hyphenated list)
- [Family history of dental or orthodontic issues]

Social History:
(hyphenated list)
- [Tobacco use]
- [Alcohol use]
- [Other relevant social factors]

Clinical Examination:
(hyphenated list)
- [Facial symmetry]
- [Profile analysis]
- [Lip competence]
- [TMJ evaluation]
- [Oral hygiene status]
- [Soft tissue examination]
- [Dental caries or restorations]
- [Periodontal status]
- [Occlusion: molar/canine relationship, overjet, overbite, crossbite, open bite]
- [Arch form and symmetry]
- [Spacing or crowding]
- [Missing or supernumerary teeth]
- [Eruption status]

Radiographic and Diagnostic Records:
(hyphenated list)
- [Panoramic radiograph findings]
- [Cephalometric analysis]
- [Photographs]
- [Study models]

Assessment:
(hyphenated list)
- [Summary of orthodontic diagnosis]
- [Malocclusion classification]
- [Skeletal and dental relationships]
- [Other relevant findings]

Treatment Plan:
(hyphenated list)
- [Recommended orthodontic appliances]
- [Estimated duration of treatment]
- [Extractions if indicated]
- [Adjunctive procedures]
- [Patient education and counselling]
- [Follow up schedule]
- [Return precautions]