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 #
Phone Type?
Other
Mobile
Home
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
Whom may we thank for recommending our services
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
Not Applicable
Last Name
First Name
Middle Name
Preferred Name
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
Home Phone
Cell Phone
Work Phone
Relationship to Patient
Employer
Occupation
Number of Years Employed
Spouse Information
Not Applicable
Spouse's Name
Preferred Name
Relationship to Patient
Employer
Occupation
Birth Date
Work Phone
Cell Phone
Emergency Information
Name of nearest relative (not living with you)
Phone Number(s)
Relationship to Patient
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
Health Questionnaire
Patient's Physician
Address
Physician's phone number
Date of most recent physical exam
General Questions
What concerns you about your teeth and jaws?
Other family members with similar condition?
Who suggested that you might need orthodontic treatment?
Have you ever had any previous orthodontic treatment or consultation?
Why did you select our office?
List interests and hobbies
NOW OR IN THE PAST HAS THE PATIENT HAD:
Diabetes
Yes
No
Asthma
Yes
No
Cancer
Yes
No
Gastrointestinal Disorders
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
Drug Problems
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
Hay Fever
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
Skin Disorder
Yes
No
Do you smoke or chew tobacco?
Do you take antibiotic pre-medication prior to dental visits?
Has the patient ever taken medication to strengthen their bones?
List any drugs, medications, nutritional supplements now being taken and give reasons
Any medical, dental, or surgical problems not covered above?
Women: Are you pregnant?
Are you trying to become pregnant?
Allergies
Do you have allergies to the following
Latex
Yes
No
Codeine
Yes
No
Dental Anesthetics
Yes
No
Erythromycin
Yes
No
Nickel or other metals
Yes
No
Aspirin
Yes
No
Penicillin
Yes
No
Tetracycline
Yes
No
Acrylics
Yes
No
Other allergies not listed
Dental History
Patient's Dentist
Reason for Last Visit
How often does the patient have dental check-ups?
Teeth Grinding or Clenching?
Past/Present Injuries To the face, mouth, or teeth?
Missing or extra permanent 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
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