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.
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
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