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Giangrasso Dental Associates                                                                Dr. Joseph Giangrasso     
311 Boston Post Road                                                                                 279 Hanover Street                                                  
Wayland, MA 01778                                                                                     Boston, MA 02113
Phone:  508-358-7100                                                                                 Phone:  617-227-6410

Name________________________________________ Date______________

Preferred Name __________________________________________________

Address________________________________________________________

City____________________________________State_______Zip__________

Telephone# Home(____)_________________________

Work (____)_________________________ Ext_______

Cell (____)____________________________________

Date of Birth_____________________________ Sex(Circle) M F

Occupation____________________________________

Employer______________________________________
                                                                                                                                                                                                                                                                          Social Security #___________--_________--______________

Name of Spouse/Closest Relative_________________________________

Phone  (____)___________________________

If you are completing this form for another person, what is your relationship to this person?                                                                   ___________________________________________________________________

How did you  hear about us?______________________________________________

Dental History:

Frequency of visits to dentist______________________________________

Type of care received___________________________________________

Difficulties with past treatment_____________________________________

Adverse reactions to local anesthetics, latex gloves, rubber dam___________

Date of most recent dental x-rays___________________________________

Do you like the appearance of your smile?____________________________

Do you like the color of your teeth?__________________________________

Medical History:

Physician Name________________________________ Phone (____)____________________

Have you had any of the following diseases or problems: (Circle One)

Bone Deformity, Fracture________________________________    Yes No

Prosthetic joint replacement______________________________    Yes No

Earache______________________________________________   Yes No

Frequent sore throat_____________________________________  Yes No

Hoarseness___________________________________________    Yes No

Respiratory problems, Bronchitis, Emphysema, Etc.___________      Yes No
 
Asthma_______________________________________________   Yes No

Tuberculosis___________________________________________   Yes No

Shortness of Breath___________________________________        Yes No

Pain, Pressure in Chest__________________________________     Yes No

Swelling of Ankles______________________________________      Yes No (OVER PLEASE)

High Blood Pressure____________________________________    Yes No                                                                           

Low Blood Pressure____________________________________    Yes No

Rheumatic Fever/Scarlet Fever____________________________  Yes No

Heart Murmur, Heart Attack, Mitral Valve Prolapse_____________    Yes No

Valve Replacements-Pacemakers__________________________   Yes No

Congenital Heart Lesions_________________________________ Yes No

Difficulties Swallowing___________________________________ Yes No

Hepatitis, Jaundice, Liver Disease__________________________ Yes No

Diabetes_____________________________________________ Yes No

Excessive Thirst________________________________________ Yes No

Thyroid Problems______________________________________ Yes No

Sexually Transmitted Disease_____________________________ Yes No

Anemia_______________________________________________ Yes No

HIV Infection, AIDS______________________________________ Yes No

Leukemia, Problems with Immune System____________________ Yes No

Spleen Problems_______________________________________ Yes No

Frequent Headaches____________________________________ Yes No

Dizziness, Fainting, Seizures______________________________ Yes No

Epilepsy or other Neurological Disease______________________ Yes No

Radiotherapy/Chemotherapy______________________________ Yes No

Other_________________________________________________ Yes No

Are you a tobacco user?__________________________________ Yes No

Are you taking any medications, including non-prescription medicine?                                                                                                                                                            (eg. aspirin, baby aspirin,corticosteroids, herbal supplements, etc.)                               Yes No
If so, what?__________________________________________________

Have you had any serious illnesses, operations, or been hospitalized within the last five years?    Yes No 
If so, what was the illness or problem?________________________________________

Do you have any known allergies or adverse reactions to any medications?                 Yes No _____________________________________________________________________

 Dental Insurance Data:

Plan Name___________________________

Subscriber's Name_________________________ Relation______________

Group #___________________ I.D.#______________________ 

Digital images taken of you or your smile may be used to educate other patients/health providers.

I do___ do not____ give Doctor Giangrasso's office permission to show my images to other patients/health providers.

Signature________________________________Date_____________                                                                                                                                                               
                                                                                                                                                                                                                                                                               Updated Signature_________________________Date_____________

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