Evaluation form

Clinical Exam Score Grid

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EVALUATION FORM
Affiliate name	Case #	Category:
Please rate each of the following areas using the following rating scale:
4 = Excellent – absolutely meets or exceed expectations
3 = Acceptable – meets expectations, perhaps with minor errors
2 = Deficient overall, with elements lacking on many or most of the cases
1 = Unacceptable = fundamentally incomplete or lacking
A.     Initial Records
I. Photographs (Includes the correct structures, good resolution,consistent magnification, not blurred)	1	2	3	4
II. Dental Casts (Appropriate extent, good detail, lack of bubbles)	1	2	3	4
III. Radiographs (Correct exposure, not blurred)	1	2	3	4
IV. Ceph tracing & analysis (Accuracy)	1	2	3	4
V. Diagnosis (completeness, detail)	1	2	3	4
VI. Treatment Plan (detail, objectives of treatment)	1	2	3	4
VII. Rationale for treatment plan	1	2	3	4
VIII. Alternative treatment plans	1	2	3	4
IX.  Mechanics (detail, efficacy)	1	2	3	4
X.     VTO (do the numbers add up?)	1	2	3	4
XI. Overall detail (history, growth status, prognosis)	1	2	3	4
B.     One year Progress Records
I. Photographs (Includes the correct structures, good resolution,consistent magnification, not blurred)	1	2	3	4
II. Dental Casts (Appropriate extent, good detail, lack of bubbles)	1	2	3	4
III. Radiographs (Correct exposure, not blurred)	1	2	3	4
IV. Ceph tracing & analysis (Accuracy)	1	2	3	4
V. Treatment Progress (accuracy, detail)	1	2	3	4
VI. Superimposition (accuracy, interpretation)	1	2	3	4
VII. Results Achieved (completeness, accuracy, detail)	1	2	3	4
VIII. Self-Assessment (validity, awareness, analysis)	1	2	3	4
C.     Two year Progress Records
I. Photographs (Includes the correct structures, good resolution,consistent magnification, not blurred)	1	2	3	4
II. Dental Casts (Appropriate extent, good detail, lack of bubbles)	1	2	3	4
III. Radiographs (Correct exposure, not blurred)	1	2	3	4
IV. Ceph tracing & analysis (Accuracy)	1	2	3	4
V. Treatment Progress (accuracy, detail)	1	2	3	4
VI. Superimposition (accuracy, interpretation)	1	2	3	4
VII. Results Achieved (completeness, accuracy, detail)	1	2	3	4
VIII. Self-Assessment (validity, awareness, analysis)	1	2	3	4
D.    Final Records
I. Photographs (Includes the correct structures, good resolution,consistent magnification, not blurred)	1	2	3	4
II. Dental Casts (Appropriate extent, good detail, lack of bubbles)	1	2	3	4
III. Radiographs (Correct exposure, not blurred)	1	2	3	4
IV. Ceph tracing & analysis (Accuracy)	1	2	3	4
I. Photographs (Includes the correct structures, good resolution,consistent magnification, not blurred)	1	2	3	4
II. Dental Casts (Appropriate extent, good detail, lack of bubbles)	1	2	3	4
III. Radiographs (Correct exposure, not blurred)	1	2	3	4
IV. Ceph tracing & analysis (Accuracy)	1	2	3	4
V. Superimposition (accuracy, interpretation)	1	2	3	4
VI. Final Results Achieved (completeness, accuracy, detail)
A. Alignment: are all teeth, including second molars, aligned with no rotations or displacements?	1	2	3	4
B. Buccolingual inclination: are posterior teeth appropriately inclined with no excessive buccal or lingual tipping?	1	2	3	4
C. Vertical: are both arches leveled, including second molars?	1	2	3	4
D. Transverse: is the buccal overjet appropriate?	1	2	3	4
E. Anteroposterior: are the buccal segments (molars, bicuspids, and canines) well intercuspated?	1	2	3	4
F. Incisor relations: are the overjet and overbite corrected, with incisors appearing to contact in occlusion?	1	2	3	4
G. Finishing: are all spaces closed unless planned to remain? Are the incisor gingival margins idealized?  Root tip consistent?	1	2	3	4
VII. Self-Assessment (validity, awareness, analysis)	1	2	3	4