Health & History FormHealth & History 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	A value is required.
Nickname
Birthdate	A value is required.Invalid format.
Sex	Male: Female:
Marital Status
Address	A value is required.
City	A value is required.
State	A value is required.
Zip	A value is required.Invalid format.
Home Phone	A value is required.Invalid format.
Work Phone	Invalid format.
E-Mail	Invalid format.
School/Employer
Spouse's Name

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.

If minor, patient lives with

Interests / Hobbies

Whom may we thank for referring you?

Information for Patients Who Are Minors

Mother's Name		Father's Name
Birthdate	Invalid format.	Birthdate	Invalid format.
Marital Status		Marital Satus
Address (if different)		Address (if different)
City		City
State		State
Zip	Invalid format.	Zip	Invalid format.
Home Phone	Invalid format.	Home Phone	Invalid format.
Work Phone	Invalid format.	Work Phone	Invalid format.
E-Mail Address	Invalid format.	E-Mail Address	Invalid format.
Employer		Employer
Position		Position

Medical and Dental History

General Dentist Physician

Present Health Good Fair 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 specify

Has patient received treatment from an allergist or ear, nose, and throat (ENT) specialist?

Yes No If yes, when?

Has patient had tonsils and/or adenoids removed? Yes No If Yes, When?

Has patient ever had any of the following conditions?
AIDS	Epilepsy	Allergies to:
Arteriosclerosis	Endocrine Problems	Antiobiotics
Asthma	Emotional Problems	Pain Pills
Autoimmune disorder	Female Problems	Dairy Products
Blood Diseases	Hepatitis	Wheat, cereal
High Blood Pressure	Heart Disease	Food dyes
Low Blood Pressure	Hearing Disorder	Latex
Bone Disorders	Kidney Disease	Dust, pollen
Cancer	Rheumatic Fever	Animals
Diabetes	Sleep disturbance	Other:
Dizziness	Trauma to face, jaws, or head	Other:
Dyslexia, ADD	Tuberculosis
Other learning disability (please specify)

Birth defects (please specify)

	Please indicate all descriptions that apply to the patient
	Jaw has "locked" open or closed	Headaches
	Snores when sleeping	Speech problems
	Breathes through mouth more than nose	Sucking habits (thumb, finger, lip, etc.)
	Frequent Colds, sore throats, or tonsilitis	Grinds or clenches teeth
	Difficulty chewing and/or swallowing	Smokes
	Pain and/or clicking in jaw joint	Previous orthodontic consultation
	Permanent teeth erupt behind baby teeth	Previous orthodontic appointment
	Teeth removed by a dentist	Unusual dental experience
	Facial cosmetic surgery	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.