orthognathic questionnaire

ORTHOGNATHIC QUESTIONNAIRE

We would appreciate it if you would fill out the following questionnaire. It will help us to determine those areas of concern that you have regarding your condition. When the facial bones are out of balance, many things can be affected, including how you look, your bite, the condition of your teeth speech, chewing, swallowing, and breathing. Knowledge of your concerns and expectations are vital to our achieving a successful result for you.

Patient First Name

Patient Last Name

Date of Birth

I. How long have you been aware of your condition?

II. Does it affect the appearance of your face? In what way?

III. Does your condition affect you: (please check)

Chew Speak Swallow Breathe

IV. Why have you chosen to have this condition corrected at this time?

V. Is your condition creating pain: (please check)

Headache Jaw Joint Pain Facial Pain Pain When Chewing

VI. Please check those that apply to you:

VII. Have your ever done the following: (please check)

Thumb or finger sucking Tongue thrusting

VIII. Please list in order of importance those functional or esthetic conditions that you would like to
see corrected through orthognathics:

Bite

Appearance

Smile

Speech

Eliminate aches and pains

Other (please list)

Please indicate the number of the profile below to which you most relate (please check)

ORTHOGNATHIC QUESTIONNAIRE

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