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 and 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 and 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 and Zip Cell Phone Other Phone E-Mail Address Employer Position
    Father’s Name Birthdate Marital Status Address (if different) City State and 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 and 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.