Adult Patient Health History Form
All sections must be complete prior to submitting.
Patient Information
Date
Patient First, Middle and Last Name
Preferred Name
Email
Preferred Phone #
Address
City
State
Select your option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Birth Date
Age
Gender
Marital Status
Employer
Whom may we thank for recommending our services
Kindly select at least one option.
Dentist
Family/Friend
Google
Social Media
Other
Names and Ages of Children in Family
Not Applicable
Name
Age
Have been seen in our office? (Yes/No)
Name
Age
Have been seen in our office? (Yes/No)
Name
Age
Have been seen in our office? (Yes/No)
Name
Age
Have been seen in our office? (Yes/No)
Responsible Party Information
Same as patient
Last Name
First Name
Middle Name
Preferred Name
Same as above
Address
City
State
Select your option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Cell Phone
Relationship to Patient
Employer
Spouse Information
Not Applicable
Spouse's Name
Preferred Name
Relationship to Patient
Employer
Birth Date
Cell Phone
Dental Insurance
Primary Insurance
(if insured's address is different than responsible party, please inform our office)
Not Applicable
Do you have Insurance coverage for dentistry?
Yes
No
Unsure
Do you have Insurance coverage for orthodontic treatment?
Yes
No
Unsure
Insured's Full Name
Insured's Birth Date
Member ID or Social Security #
Relationship to Patient
Insurance Company
Phone # for Provider Services
Group #
Insured's Employer
Secondary Insurance
(if insured's address is different than responsible party, please inform our office)
Not Applicable
Do you have Insurance coverage for dentistry?
Yes
No
Unsure
Do you have Insurance coverage for orthodontic treatment?
Yes
No
Unsure
Insured's Full Name
Insured's Birth Date
Member ID or Social Security #
Relationship to Patient
Insurance Company
Phone # for Provider Services
Group #
Insured's Employer
Fee Expectations
If treatment is recommended for you, what is your ideal DOWN payment?
$350 - $499
$500 - $749
$750 +
I would like to pay in full and receive a courtesy discount
I have an HSA or FSA I would like to use
If treatment is recommended for you, what is your ideal MONTHLY payment?
$100 - $199
$200 - $299
$300 - $399
I have an HSA or FSA I would like to use
If treatment is recommended for you, what is your desired time frame to begin this exciting journey?
I would like to get started today
I would like to get on the schedule
I am shopping around for other opinions
I am unsure
General Questions
List any drugs or medications now being taken and give reasons
What concerns you about your teeth and jaws?
Have you ever had any previous orthodontic treatment or consultation?
List interests and hobbies
NOW OR IN THE PAST HAS THE PATIENT HAD:
Diabetes
Yes
No
ADHD/ADD
Yes
No
Asthma/COPD
Yes
No
Cancer
Yes
No
Radiation/Chemotherapy
Yes
No
Mitral Valve Prolapse
Yes
No
Ulcers
Yes
No
Rheumatic Fever
Yes
No
Bone Disorders
Yes
No
Sleep Apnea
Yes
No
Birth/Hereditary Problems
Yes
No
Arthritis or Joint Problems
Yes
No
Low Blood Pressure
Yes
No
Tuberculosis
Yes
No
Anemia
Yes
No
Epilepsy/Seizure
Yes
No
Herpes
Yes
No
Sickle Cell
Yes
No
Stroke
Yes
No
HIV/AIDS
Yes
No
Hepatitis
Yes
No
Heart Defect, Murmur
Yes
No
Immune System Problems
Yes
No
Depression/Mental Health
Yes
No
Heart disease, Heart attack
Yes
No
Endocrine or Thyroid
Yes
No
Prolonged Bleeding
Yes
No
Handicap/Disability
Yes
No
Hearing Impairment
Yes
No
Sinus Problems
Yes
No
Liver Involvement
Yes
No
Fainting or Dizziness
Yes
No
Nervous Disorders
Yes
No
Kidney Involvement
Yes
No
History of Eating Disorders
Yes
No
High Blood Pressure
Yes
No
Do you smoke or chew tobacco?
Yes
No
Do you take antibiotic pre-medication prior to dental visits?
Any medical, dental, or surgical problems not covered above?
Has the patient ever taken medication to strengthen their bones?
Yes
No
List any drugs or medications now being taken and give reasons
Women: Are you pregnant?
Yes
No
NA
Are you trying to become pregnant?
Yes
No
NA
Allergies
Please select at least one allergy option.
Do you have allergies to the following
Latex
Yes
No
Dental Anesthetics
Yes
No
Acrylics
Yes
No
Erythromycin
Yes
No
Nickel or other metals
Yes
No
Penicillin
Yes
No
Seasonal
Yes
No
Other allergies not listed
Not Applicable
Dental History
Patient's Dentist
Teeth Grinding or Clenching?
Past/Present Injuries To the face, mouth, or teeth?
Clicking or discomfort in jaw joints near ears?
treated for "TMJ" or "TMD"?
To the best of my knowledge, the health information is complete and correct. I will not hold Cranford Orthodontics responsible for any errors or omissions that I have made in completing this form. I will notify Cranford Orthodontics of any changes in my medical or dental health. I understand that where appropriate, credit bureau reports may be obtained. I have also received a copy and read the notice of privacy practices.
Date
Signature of Patient or Parent if Patient is a Minor
Thank you for completing the above information. Please only click the “Submit” button once, as it may take a few moments to process. Once successfully submitted, you will be redirected back to the previous page and a confirmation message will appear.