HEALTH FORM

HEALTH FORM Please complete the information requested in this form and press the “Submit” button at the bottom. By submitting this form I acknowledge that this information is true and correct as of this date, and I give my permission for Dr. Hang to communicate with other healthcare professionals regarding treatment recommended. Please be assured all information submitted will be held in strict confidence.

Patient Information

Name
Nickname
Birthdate
Sex  Male Female
Marital Status
Address
City
State
Work Phone
E-Mail
School/Employer
Spouse’s Name
If minor, patient lives with
Interests / Hobbies
Whom may we thank for referring you?

Responsible Party Information

Name
Relationship to Patient
Address (if different)
City
State
Zip
Birthdate
Marital Status
Home Phone
Work Phone
E-Mail
Employer
Dental Insurance Co.

Information for Patients Who Are Minors

Mother’s Name
Birthdate
Marital Status
Address (if different)
City
State
Zip
Home Phone
Work Phone
E-Mail Address
Employer
Position
Father’s Name
Birthdate
Marital Status
Address (if different)
City
State
Zip
Home Phone
Work Phone
E-Mail Address
Employer
Position

Medical and Dental History

General Dentist
Physician
Present Health  Good Poor
Specific drugs or medications currently taken
Has patient been under the care of a physician during the past 2 years other than for routine examinations?  Yes No
Please describe any medical, dental……
Has patient received treatment from an allergist or ear, nose, and throat (ENT) specialist?
 Yes No
Has patient had tonsils and/or adenoids removed?  Yes No
If yes, when?

Has patient ever had any of the following conditions?

 AIDS
 Arteriosclerosis

 Asthma
 Autoimmune disorder
 Blood Diseases
 High Blood Pressure
 Low Blood Pressure
 Bone Disorders
 Cancer
 Diabetes
 Dizziness
 Dyslexia, ADD

 Epilepsy
 Endocrine Problems
 Emotional Problems
 Female Problems
 Hepatitis
 Heart Disease
 Hearing Disorder
 Kidney Disease
 Rheumatic Fever
 Sleep disturbance
 Trauma to face, jaws, or head
 Tuberculosis
Allergies to:
 Antiobiotics
 Pain Pills
 Dairy Products
 Wheat, cereal
 Food dyes
 Latex
 Dust, pollen
 Animals
Other
Other
Other learning disability (please specify)
Birth defects (please specify)

Please indicate all descriptions that apply to the patient :

 Jaw has “locked” open or closed
 Snores when sleeping
 Breathes through mouth more than nose
 Frequent Colds, sore throats, or tonsilitis
 Difficulty chewing and/or swallowing
 Pain and/or clicking in jaw joint
 Permanent teeth erupt behind baby teeth
 Teeth removed by a dentist
 Facial cosmetic surgery
 Headaches
 Speech problems
 Sucking habits (thumb, finger, lip, etc.)
 Grinds or clenches teeth
 Smokes
 Previous orthodontic consultation
 Previous orthodontic treatment
 Unusual dental experience
Please specify
Please describe any medical, dental or surgical problems not covered above
Names and ages of siblings if patient is a minor
 Family members with similar orthodontic condition Mother Father Brother Sister Grandmother Grandfather Other

William M. Hang, DDS, MSD – A Professional Corporation – has taken special precautions to provide secure transmission of personal information on its website.

I confirm that I have been given access to the Notice of Privacy Practices of William M. Hang, DDS, MSD – A Professional Corporation. Link to Notice of Privacy Practices Before submitting your form, please print it out and keep a copy for your records.

 To the best of my knowledge, this information is true and accurate as of this date.I hereby give Dr.Hang my permission to communicate with other healthcare professional regarding treatment recommended. I acknowledge that I have access to the Notice of Privacy Practices.
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