Dental Clinic Pro Toolkit
A complete toolkit for established dental clinics, including an annual care membership agreement and an in-depth orthodontic progress review
Get started with PocperA complete toolkit for established dental clinics, including an annual care membership agreement and an in-depth orthodontic progress review
Get started with PocperThis review is completed by you, the patient, partway through your orthodontic treatment. Your honest answers about comfort, wear time, and daily care help your orthodontist adjust your plan and keep your treatment on track. The clinic section at the top is filled in by the practice before you receive this form.
The following details are completed by the practice.
Patient name:
Appliance type:
Treatment start date:
Review stage / month:
Date you are completing this review:
How comfortable have your braces or aligners been since your last visit?
Comfortable
Mild soreness
Frequently painful
Have you had any of the following? Tick all that apply:
A broken bracket or wire
A poking or rubbing wire
A lost or cracked aligner
Mouth ulcers or sores
None of these
Please describe any comfort issues in your own words:
The comfort and fit details above reflect my own experience honestly.
Please tell us honestly how you have been wearing and caring for your appliance. Fill in the right-hand column with your own answer.
Question | Your answer |
|---|---|
Average hours per day you wear your aligners / elastics | |
Times per day you brush | |
How often you floss / use interdental brushes | |
Aligners lost or skipped since last visit |
Which foods or habits have been hardest to keep up with? Tick all that apply:
Avoiding hard or sticky foods
Wearing elastics as instructed
Cleaning after every meal
None — I have kept up with everything
The wear-time and care details above are accurate to the best of my knowledge.
How happy are you with the progress you can see so far?
Very happy
Somewhat happy
Not sure yet
Concerned about progress
What changes have you noticed in your teeth or bite?
Is there anything worrying you, or any question you want to raise at your next visit?
Optional — upload a recent photo of your smile or a broken part:
The answers I have given in this review are true and complete to the best of my knowledge.
I understand that keeping to the wear and care instructions affects how long my treatment takes.
I would like my orthodontist to review the concerns I raised above at my next appointment.
Patient (or parent/guardian) — printed name:
Date:
Thank you for taking the time to complete this review. Your feedback helps your orthodontist give you the best possible result.
The Orthodontic Treatment Progress Review template is a ready-to-use form from Pocper's Dental Clinic Pro Toolkit pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.