Patient Information
Whom may we thank for referring you to our practice?
First Name:
Middle Initial:
Last Name:
Prefers to be called:
Birthdate:
Gender:
Male
Female
Other
Home Address:
City:
State:
Zip:
Primary Phone:
Type:
Cell
Home
Work
Secondary Phone:
Type:
Cell
Home
Work
Email:
Employer:
Job Title/Occupation:
Who is financially responsible for the account?
If the patient is your child, please help us get to know them better:
School:
Grade:
Favorite Class:
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
How many brothers:
Ages:
How many sisters:
Ages:
Parent/Guardian (if patient is a minor)
Custodial parent/s name/s
Patient lives with (check all that apply)
Mother
Father
Stepparent
Grandparent
Father's First Name:
Middle Initial:
Last Name:
Address (if different):
City:
State:
Zip:
Father's Cell Phone:
Work Phone:
Alternate Phone:
Email:
Birthdate:
Employer:
Job Title/Occupation:
Mother's First Name:
Middle Initial:
Last Name:
Address (if different):
City:
State:
Zip:
Mother's Cell Phone:
Work Phone:
Alternate Phone:
Email:
Birthdate:
Employer:
Job Title/Occupation:
Who will be with patient at the appointments?
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Policy Holder's Employer:
Orthodontic coverage?
No
Yes
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Policy Holder's Employer:
Orthodontic coverage?
No
Yes
Medical History
Is the patient in excellent health?
Yes
No
Has there been any change in the patient's general health within the last year?
Yes
No
Last physical exam was:
Is the patient now under the care of a physician? If so, please describe
Yes
No
Has there been a serious illness or hospitalization in the past 5 years? If so, please describe
Yes
No
Please list any medications currently being taken by the patient (include non-prescription):
Is the patient currently taking, or has taken in the past 5 years, Bisphosphonates (Fosamax Aredia, etc.)?
Yes
No
Does the Patient require antibiotics before dental visits?
Yes
No
If so, please describe
Please signify 'Yes' or 'No' if patient has any of the following health conditions:
Allergies or drug reaction to:
Latex
Yes
No
Metal/Nickel
Yes
No
Sulfa drugs
Yes
No
Aspirin, Ibuprofen, or Tylenol
Yes
No
Antibiotics
Yes
No
Local anesthetics
Yes
No
Codeine or other narcotics
Yes
No
Please list any other food, antibiotic, or general allergies or sensitivities that the patient may have:
Respiratory problems or emphysema
Yes
No
Asthma
Yes
No
Sinus trouble
Yes
No
Persistent swollen neck glands
Yes
No
Thyroid or endocrine problems
Yes
No
Diabetes
Yes
No
Hepatitis
Yes
No
Jaundice or liver disease
Yes
No
AIDS or HIV infection
Yes
No
Sexually transmitted disease
Yes
No
Substance abuse problem (past or present)
Yes
No
Mental health problem or nervous disorder
Yes
No
Epilepsy or other neurological disease
Yes
No
Fainting spells
Yes
No
Seizures
Yes
No
Tonsils removed
Yes
No
Adenoids removed
Yes
No
Tendency to be a mouth breather
Yes
No
Snoring troubles
Yes
No
Sleep Apnea
Yes
No
Anemia or blood disorder
Yes
No
Abnormal bleeding or blood transfusion
Yes
No
Low blood pressure
Yes
No
Cardiovascular disease (heart trouble, heart attack, angina, high blood pressure, arteriosclerosis, stroke)
Yes
No
Damaged or artificial heart valves, including heart murmur or rheumatic heart disease
Yes
No
Arthritis, joint problems or artificial joints/limbs
Yes
No
Birth defects
Yes
No
Kidney trouble
Yes
No
Tuberculosis
Yes
No
Vision, hearing or speech difficulty
Yes
No
Stomach ulcer or hyperacidity
Yes
No
Tumor (cancerous or benign)
Yes
No
Radiation or Therapy/Chemotherapy
Yes
No
Acid Reflux
Yes
No
FEMALES: Are You Pregnant?
Yes
No
Current or past use of tobacco products
Yes
No
If you answered 'Yes' to any of the above, or if you feel there are any other conditions that we should be aware of, please describe:
Dental History
Dentist Name:
Last Dental Visit:
Please signify 'Yes' or 'No' if patient has any of the following dental conditions:
Chipped or injured permanent teeth
Yes
No
Teeth sensitive to hot or cold
Yes
No
Previous root canal therapy
Yes
No
Bleeding gums or bad taste/mouth odor
Yes
No
Periodontal (gum) problems/treatment
Yes
No
Problems with food trapped between teeth
Yes
No
Abnormal swallowing (tongue thrust)
Yes
No
Any past negative dental experiences
Yes
No
Bone fractures or trauma to face or jaw
Yes
No
Loose or shifting teeth
Yes
No
Is the diet high in sweets/sugars
Yes
No
Have wisdom teeth been removed
Yes
No
Have any permanent teeth been removed
Yes
No
History of missing teeth
Yes
No
Teeth that irritate tongue, cheek, lip
Yes
No
Previous orthodontic treatment or retainer
Yes
No
Damaged restorations or fillings
Yes
No
Past/present thumb or finger habit
Yes
No
All dental work is currently completed
Yes
No
TMJ History
Has a TMJ screening been performed
Yes
No
Past or current TMJ treatment
Yes
No
History of jaw joint problems
Yes
No
Frequent headaches
Yes
No
Past or current grinding of teeth
Yes
No
Past or current clenching of teeth
Yes
No
Past or current locking of jaw
Yes
No
Difficulty chewing or opening your mouth
Yes
No
Bite feels uncomfortable or unusual
Yes
No
Past or current pain in jaw joint:
Left
Right
Both
N/A
Clicking or popping in jaw joint:
Left
Right
Both
N/A
Do you and/or the patient's dentist have any specific concerns that you would like Dr. Race to evaluate? If so, please describe:
We are pleased to participate in social media outlets such as Facebook, Instagram, etc. Through these venues, we share staff pictures, office updates, new contests and exciting patient events and accomplishments. With the expressed permission of our patients, we are pleased to share their posts welcoming new patients to our practice, congratulating patients completing their treatment, and posting photos of our patients' beautiful new smiles.
"I give my consent to allow Race Orthodontics to post updates or photographs of me/my child on social media."
"I authorize Dr. Kevin T. Race to perform diagnostic procedures and treatments as may be necessary for orthodontic care. I authorize release of any information regarding my/my child's orthodontic treatment to my dental insurance company."
"I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that the questions presented have been answered to my satisfaction. I will not hold my orthodontist or any other member of his staff responsible for any errors or omissions that I have made in the completion of this form.
I certify that I am the adult patient or the legal guardian of the above-named patient. If there are any changes later to this history record or medical or dental status, it is my responsibility to inform the practice."