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 MaleFemale
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 GoodPoor
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? YesNo
Please describe any medical, dental……
Has patient received treatment from an allergist or ear, nose, and throat (ENT) specialist?
YesNo
Has patient had tonsils and/or adenoids removed? YesNo
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 conditionMotherFatherBrotherSisterGrandmotherGrandfatherOther

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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