Health History Form

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 & Zip Cell Phone Other 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 Cell Phone Other 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 Cell Phone Other Phone E-Mail Address Employer Position
Father’s Name Birthdate Marital Status Address (if different) City State & Zip Cell Phone Other 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 Specify Has patient received treatment from an allergist or ear, nose, and throat (ENT) specialist? YesNo

Name of Specialist:

Has patient had tonsils and/or adenoids removed? 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:
Antibiotics Pain Pills Dairy Products Wheat, cereal Food dyes Latex Dust, pollen Animals 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 tonsillitis
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 describe any medical, dental or surgical problems not covered above

Privacy & Submit

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 professionals regarding treatment recommended.

Here is the link to William M Hang, DDS, MSD - A Professional Corporation’s Notice of Privacy Practices: Notice of Privacy Practices

I acknowledge I have been given access to the Notice of Privacy Practices and accept them.

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