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DeDomenico Orthodontics Child Medical History Form

DeDomenico-Child-Medical-History-Form

Date

CONFIDENTIAL

Birth Date:
Sex:
Patient lives with:
Date Last Seen:
Date Last Seen:

RESPONSIBLE PARTY

D.O.B.:

INSURANCE INFORMATION

Insurance Coverage for Orthodontic Treatment?
Birth Date:
Birth Date:
For the following questions mark yes, no, or don't know/understand (dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

PATIENT PROFILE

Does patient follow directions well?
Does patient brush his/her teeth conscientiously?
Does patient have learning disabilities or need extra help with instructions?
Is patient sensitive or self-conscious about teeth?

MEDICAL HISTORY

Now or in the past, have you had:
Birth defects or hereditary problems?
Bone fractures, any major accidents?
Rheumatoid or arthritic conditions?
Endocrine or thyroid problems?
Kidney problems?
Diabetes?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer or hyperacidity?
Polio, mononucleosis, tuberculosis, pneumonia?
Problems of the immune system?
AIDS or HIV positive?
Hepatitis, jaundice or liver problem?
Fainting spells, seizures, epilepsy or neurological problem?
Mental health disturbance or depression?
Vision, hearing, tasting or speech difficulties?
Loss of weight recently, poor appetite?
History of eating disorder (anorexia, bulimia)?
Excessive bleeding or bruising tendency, anemia or bleeding disorder?
High or low blood pressure?
Tired easily?
Chest pain, shortness of breath or swelling ankles?
Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease)?
Does the patient currently have or ever had a substance abuse problem?
Does the patient chew or smoke tobacco?
Operations? Describe:
Hospitalized? Describe:
Other physical prunes or symptoms? Describe:
Being treated by another health care professional?
Skin disorder?
Does the patient eat a well-balanced diet?
Frequent headaches, colds or sore throats?
Eye, ear, nose or throat condition?
Hayfever, asthma, sinus trouble or hives?
Tonsil or adenoid conditions?

Allergies or reactions to any of the following:

Local anesthetics s(Novocaine or Lidocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin or other antibiotics
Sulfa drugs
Codeine or other narcotics
Metals (jewelry, clothing snaps)
Latex (gloves, balloons)
Vinyl
Acrylic
Animals
Foods (specify)
Other substances (specify)
Is the patient taking medication, nutrient supplements, herbal medications or non prescription medicine? Please name them.

GIRLS ONLY

Has the patient started her monthly periods? If so, approximately when?
Is the patient pregnant?

FAMILY MEDICAL HISTORY

Do your parents or siblings have, or have ever had any of the following health problems? If so, please explain.

DENTAL HISTORY

Now or in the past, have you had:
Started teething very early or late?
Primary (baby) teeth removed that were not loose?
Permanent or "extra" (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or otherwise injured primary (baby) or permanent teeth?
Teeth sensitive to hot or cold; teeth throb or ache?
Jaw fractures, cysts or mouth infections?
"Dead teeth" or root canals treated?
Periodontal "gum problems"?
Bleeding gums, bad taste or mouth odor?
Food impaction between teeth?
"Gum boils", frequent canker sores or cold sores?
Thumb, finger, or sucking habit?
Abnormal swallowing habit (tongue thrusting)?
History of speech problems?
Mouth breathing habit, snoring or difficulty in breathing?
Tooth grinding or jaw clenching?
Any pain, clicking or locking in jaw or ringing in the ears?
Any pain or soreness in the muscles of the face or around the ears?
Difficulty in chewing or jaw opening?
Aware of loose, broken or missing restorations (fillings)?
Have you ever been treated for "TMD" or "TMJ" problems?
Any teeth irritating cheek, lip, tongue or palate?
Concerned about spaced, crooked or protruding teeth?
Aware or concerned about under or over developed jaw?
Taking any forms of fluoride?
Any relative with similar tooth or jaw relationships?
Had periodontal (gum) treatment?
Would you object to wearing orthodontic appliances (braces) should they be indicated?
Any serious treuble associated with any previous dental treatment?
Ever had a prior orthodontic examination or treatment?
Been under another dentist's care?
I have read and understand the above questions.(Required)
Clear Signature
(Parent or Guardian)
Date Signed:
Clear Signature
(Dental staff member)
Date Signed:
I understand that where appropriate(Required)

DeDomenico Orthodontics in Tampa, Lutz, Brooksville

We provide orthodontic excellence in a comfortable and friendly environment. We use only the best and up-to-date techniques. Our computer technology includes advanced graphics and digital imaging to insure the best care available.

Meet the Doctors

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    Ralph DeDomenico, D.M.D.
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    Matthew DeDomenico, D.M.D.
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DeDomenico Orthodontics

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My daughter has been going to DeDomenico Orthodontics for almost two years. Her teeth were a train wreck! What DeDomenico Orthodontics was able to with her teeth is no short of a miracle, especially in such a short amount of time. She was also a kid that was extremely terrified of dentists and their staff has done such a spectacular job of making her comfortable that her anxiety about dentists and orthodontists has done a 180. As a middle-school child she is a lot more confident in her appearance and I am grateful to their team to helping her get back a great smile!

Tammy P

My son and daughter have both received braces at DeDomenico Orthodontics and I cannot say enough about how friendly, professional, and courteous the entire staff is. I would definitely recommend DeDomenico Orthodontics to family and friends.

Rene Brioso

The workers at DeDomenico are like family they treat you with lots of care when getting work done. They have an open environment which makes it easier to relax. When getting work done in your mouth you don’t want dirty instruments touching your mouth. DeDomenico make sure that everything they use is well kept and clean. They are very careful and make you as comfortable as possible.

Jakob Salgado

We have two children currently receiving braces at DeDomenicos. We could not be more pleased with the service we are receiving. A frendly, courtious, and professional establishment.

Gary First

Dr. DeDomenico is an Invisalign Preferred Provider and a brilliant orthodontist! His office in Tampa is staffed with great people and he is able to attune himself to the wishes and needs of every single patient. Thank you very much!

Jim Cramer

Our daughter received personalized, hands-on care from Dr. DeDomenico and his wonderful staff. We are very happy with the results and highly recommend DeDomenico Orthodontics.

Steve Kenyon

I can’t say enough about Dr. Matt and the staff at DeDomenico Orthodontics. They were straightforward with me regarding pricing, treatment time, and clearly explaining to me what my expectations should be. However, my actual results were even better than what I was told I should expect. I’d highly recommend them to anyone looking to improve upon their smile!

Vic Granowicz
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