David D. Gianino ~ Dental Care in Lunenburg, Massachusetts 01462 ~ Untitled Document

40 Mass. Ave. ~ Lunenburg, Massachusetts 01462

Patient Information

Health Information

Previous Dentist::	AIDS	Date of Last Dental Visit::
Anemia	Reason for this visit::	Arthritis
Allergies::	Artificial Joints	Allergic/Adverse Reaction to Medication or Any Substance::
Artificial Heart Valve	Asthma	Blood Disease
Bruise Easily	Cancer	Cold Sores/Fever Blisters
Contact Lenses	Cortisone Medication	Diabetes
Diet	Dizziness	Emphysema
Epilepsy	Excessive Bleeding	Fainting
Glaucoma	Growths	Hay Fever
Head Injuries	Heart Murmur	Hemophilia
Hepatitis	High Blood Pressure	Jaundice
Kidney Disease	Latex Sensitivity	Liver Disease
Mental Disorders	Mitral Valve Prolapse	Nervous Disorders
Pacemaker	Psychiatric/Psychological	Pregnancy
Radiation Treatment	Respiratory Problems	Rheumatism
Sinus Problems	Smoke/Chew Tobacco	Stomach Problems
Stroke	Thyroid Problems	Tuberculosis
Tumors	Ulcers	Venereal Disease
Codeine Allergy	Penicillin Allergy

Health Information (cont.)

Have you ever had any complications following dental treatment:
Have you been admitted to a hospital or needed emergency care during the past two years:
Are you now under the care of a physician:
Name/phone of Physician::
Do you have any health problems that need further clarification:
Are you taking any medications:

Cosmetic information

What would you like to change the most about the appearance of your teeth:
Are all your teeth in alignment:
Do you have missing or chipped teeth:
Is your bite comfortable when chewing:
Do you have frequent headaches:
Do you have any old filings or dental treatment that you are unhappy with:
Is there anything else that you would like us to know:

Referral Information

Whom may we thank for referring you to our practice:
Name of person or office referring you to our practice::

Responsible Party Information

Employment Information

Insurance Information

Name of Insured::	Is insured a patient:	Insured's Birth Date::
ID:	Group:	Insured's Address::
City::	State::	Zip Code::
Insured's Employer Name::	Patient's relationship to insured::	Insurance Plan name and Telephone::

Online Patient Registration Forms