Orthodontic department outcome measures Clinician to completePlease complete on day of debondPatient hospital number(Required) Consultant in charge of treatment(Required) CS NJ RSK Is the consultant treating this patient?(Required) Yes No If no, what is the grade of the clinician? StR Post CCST What are the initials of the clinician? Presenting malocclusion(Required) Class I Class II/1 Class II/2 Class III Class type(Required) Routine orthodontics Interceptive Multidisciplinary If multidisciplinary (select all that apply) Orthognathic Restorative including hypodontia Cleft Oral surgery/impacted teeth Paediatric Appliance type (tick as many as required)(Required) Functional + Fixed Fixed Single arch fixed Functional only Fixed-functional (Forsus) URA + Fixed URA only Other If other Treatment start date(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Treatment end date(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Total number of appointments (From seps or fit appliance to debond, excluding cas appts)(Required)Transfer patient(Required) Yes No If yes, what was the grade of the initial treating clinician? StR Post CCST What are the initials of the clinician? Treatment completed as planned(Required) Yes No If no, state reasons Treatment evaluation: Patient to completeThis questionnaire asks for your views of the treatment that you have received. Your answers will be treated with the strictest confidentiality.1. How would you rate your relationship with your orthodontist?(Required) Very poor Poor OK Good Excellent 2. How satisfied are you with your teeth now?(Required) Very dissatisfied Dissatisfied OK Satisfied Very satisfied 3. How much do you think the problems with your teeth have improved?(Required) Greatly worsened Worsened No change Improved Greatly improved 4. How likely are you to recommend this department to your friends and family?(Required) Very unlikely Unlikely Maybe Likely Very likely 5. Is there anything you feel we could improve to have made your treatment better?(Required) Patient diversity: patient to completeThe information you give us helps us understand if patients from across our community have different experiences. We use this information to help us to plan our services to best meet the needs of everyone.Are you(Required) The patient Parent/guardian (completing on behalf of patient) Sex(Required) Female (including trans female) Male (including trans male) Non binary Other (gender not listed) Prefer not to say Age group(Required)Under 1616-1819+Do you have physical or mental health conditions, disabilities or illnesses that have lasted or are expected to last for 12 months or more?(Required) No Yes Prefer not to say If yes, select all that apply Physical impairment Long-standing illness Learning disability/difficulty Mental health condition Sensory impairment Other (not listed) Prefer not to say Other - please state
