Raymond F. Tinucci, D.M.D.

Name:________________________

Address:______________________

Home Phone:__________________

Employer:_____________________

Employer Address:______________

______________________________

Age:___________________

City:___________________

SS#:___________________

Employer Phone:

_______________________

Date:_____________

Birthdate:__________

Zip:_______________

Father/Mother/Spouse:___________

SS#__________________________

Employer Address:______________

______________________________

Birthdate:_______________

Employer Phone:

_______________________

Dental Insurance:________________

Group#:________________________

Carrier's Address:_______________

______________________________

Subscriber's Name:___________________________

Plan#:______________________________________

Physician's Name:____________________________

1. Are you under any medical treatments now? 2. Have you had any change in health in the past year? 3. Are you limited in your activity? 4. Have you been hospitalized in the past 3 years? 5. Are you pregnant?	Yes No Yes No Yes No Yes No Yes No
If any of the above were circled "yes", please complete the lower portion of this form.

List all medications that you are taking and are allergic to:

Medications		*Allergies*

Please list any significant medical problems:


Patient Signature		Dentist		Date

Please CIRCLE if you have had any of the following:

Scarlet Fever
Heart Trouble
Thyroid Disease
Shortness of Breath
Drug Addiction
Sinus Trouble
Heart Murmur
Chemotherapy / Radiation
Stroke
Arthritis / Gout
Diabetes
Cold Sores
Liver Disease
Heart Surgery
Glaucoma
Blood Disease
Bruise Easily
Yellow Jaundice

Cancer
Chest Pain
Psychiatric Care
Hay Fever
Low Blood Pressure
X-ray or Cobalt Tmt.
Fainting / Dizziness
Hemophilia
Lung Disease
AIDS
Tuberculosis
Heart Pacemaker
Cortisone Medicine
Kidney Trouble
Herpes
Ulcers
Anemia
Nervousness

Hypoglycemia
Asthma
High Blood Pressure
Parathyroid Disease
Swelling of Feet / Hands
Blood Transfusion
Emphysema
Rheumatic Fever
Frequent Cough
Congenital Heart Lesion
Pain in Jaw Joints
Artificial Joints / Hips
Fever Blisters
Hepatitis A (infection)
Hepatitis B (serum)
Epilepsy or Seizures
Allergies
Sickle Cell Anemia

Have you had any serious illness not listed above? Yes No
If yes, please describe in detail: __________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Do you wish to talk to the Doctor privately about any problem? Yes No

X __________________________________________________ Date:____________________
Patient Signature (Parent or Guardian)

Reviewed by: Doctor _________________________Date:____________________B.P_______.

Medical Updates:

I have read my MEDICAL HISTORY dated ____________ and confirm that it adequately states past and present conditions.

DATE	EXCEPTIONS	PATIENT'S SIGNATURE	B.P.	REVIEWED BY

Raymond F. Tinucci, D.M.D.
Family Dentistry
Voice 610.326.8770
Fax 610.326.3935
703 High Street
Pottstown, PA 19464