Questionnaire Q1.1: Patient name?*Q1.2: Patient Age? (doctor)*Kid > 10AdultChild < 10 ( Phase 1 - 2 years away from full tx)Q2: Current AP relationship (doctor)*Class IClass II mild (2mm – elastic jump)Class II moderate (end-on – distalization)Class II severe (full Class II)Class III mild 1-2mm (elastic jump)Class III moderate 2+mm (sequential distalization)Q3: Class II Div ___? (doctor)*Div 1Div 2Q4: Desired effect on upper incisor inclination (doctor)*Want retroclinationMaintainWant proclinationQ5: Desired effect on lower incisor position? (doctor)*Want retroclinationMaintainWant proclinationQ6: Correct AP With? (doctor)*MAFElasticsSequential mesialization / distalizationExtractionsSurgerySequentiall mesialization distalization selection 1 Sequential distalization Quadrant*Quadrant Q1 Q2 Q3 Q4 Sequentiall mesialization distalization selection 2 Sequential mesialization Quadrant*Quadrant Q1 Q2 Q3 Q4 Extractions ____text____Surgery ______text______*Q7: Current vertical relationship? (doctor)*Open – from 6sOpen – from 4sDeepbite – severeDeepbite – moderateDeepbite – mildNormalMinimalQ8: Archform / Transverse? (Doctor)*MaintainExpand mildExpand moderateExpand severe to 7sExpand 3+mm (Phase 1 only)Skeletal Posterior crossbite Y/NSkeletal Posterior crossbite selection*YesNocorrect skeletal crossbite?*Correct skeletal crossbite?YesNoQ9: Limitations of treatment? (doctor) Maintain posterior crossbite at: Maintain posterior crossbite at:How much Class II correction expected: How much Class II correction expected: How much Class II correction expected:How much Class III correction expected: How much Class III correction expected: How much Class III correction expected:Other: Other: Other:NONE NONE Q10: Extraction (best guess)? (doctor) Extract 2nd premolars Extract 2nd premolars* 15 25 35 45 Extract 1st premolars Extract 1st premolars Extract 1st premolars* 14 24 34 44 Lower incisor Lower incisor Extract 1st premolars* 42 41 31 32 Other Other Other:*NONE NONE Q11: Other situations (tech) Diastema closure Other situations (tech) Lingually displaced teeth Lingually displaced teeth type*Ectopic / Impacted canines Ectopic / Impacted canines Ectopic / Impacted canines selections 13 23 33 43 8s present 8s present 8s present selection* 18 28 38 48 will presence of 8s affect sequential distalization?*YesNoSevere anterior spacing / lots of retraction. Severe anterior spacing / lots of retraction. severe anterior spacing selections* Upper Lower Do you want to addsequential mesialization (question 6) to help with space closure*YesNoAnterior crossbite Anterior crossbite Single tooth posterior crossbite (dental) indicate teeth: Single tooth posterior crossbite (dental) indicate teeth: Single tooth posterior crossbite (dental) indicate teeth selection*NONE NONE Q12: Esthetic Over Corrections U/L3-3 (tech) Rotation (M/D) Please specify tooth numbers*Extrusion Extrusion Extrusion tooth numbers*Intrusion Intrusion Intrusion tooth numbers*In-outs (B/L) In-outs (B/L) In-outs (B/L) tooth numbers*NONE NONE Q13: Number of trays*2533445566Let software decide This iframe contains the logic required to handle Ajax powered Gravity Forms.