Adult Patient Health History Form

All sections must be complete prior to submitting.

Patient Information

Date

Patient First, Middle and Last Name

Preferred Name

Preferred Phone #

Phone Type?OtherMobileHome

Birth Date

Age

Gender

Marital Status

Whom may we thank for recommending our services

Names and Ages of Children in Family

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

Last Name

First Name

Middle Name

Preferred Name

Home Phone

Cell Phone

Work Phone

Relationship to Patient

Employer

Occupation

Number of Years Employed

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

Primary Insurance (if insured's address is different than responsible party, please inform our office)

Do you have Insurance coverage for dentistry?YesNoUnsure

Do you have Insurance coverage for orthodontic treatment?YesNoUnsure

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)

Do you have Insurance coverage for dentistry?YesNoUnsure

Do you have Insurance coverage for orthodontic treatment?YesNoUnsure

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

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 discountI 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 - $399I 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 scheduleI am shopping around for other opinionsI am unsure

Health Questionnaire

Patient's Physician

Address

Physician's phone number

Date of most recent physical exam

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:

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?

Do you have allergies to the following

Other allergies not listed

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

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.