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
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?__________________________________
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 _____________________________________________________________________
