Download the necessary form(s), print it out and fill in the required information.
Patient Registration Form
Health History - English
Health History - Russian
Financial Agreement Form
Primary insured name:
Insurance phone number:
Patient Identification Number:
1. Is your general health good?
2. Has there been a change in your health within the last year?
3. Have you been hospitalized or had a serious illness in the last three years?
If YES, why?
4. Are you being treated by a physician now? For what?
Date of last medical exam?
Date of last Dental exam?
5. Have you had problems with prior dental treatment?
6. Are you in pain now?
7. Chest pain (angina)?
8. Swollen ankles?
9. Shortness of breath?
10. .Recent weight loss, fever, night sweats?
11. Persistent cough, coughing up blood?
12. Bleeding problems, bruising easily?
13. Sinus problems?
14. Difficulty swallowing?
15. Diarrhea, constipation, blood in stools?
16. Frequent vomiting, nausea?
17.Difficulty urinating, blood in urine?
19. Ringing in ears?
21. Fainting spells?
22. Blurred vision?
24. Excessive thirst?
25. Frequent urination?
26. Dry mouth?
28. Joint pain, stiffness?
29. Heart disease?
30. Joint pain, stiffness?
31. Yes No Heart murmurs?
32. Rheumatic fever?
33. Stroke, hardening of arteries?
34. High blood pressure?
35. Asthma, TB, emphysema, other lung diseases?
36. Hepatitis, other liver disease?
37. Stomach problems, ulcers?
38. Allergies to: drugs, foods, medications, latex?
39. Family history of diabetes, heart problems, tumors?
41. Tumors, cancer?
42. Arthritis, rheumatism?
43. Eye diseases?
44. Skin diseases?
46. VD (syphilis or gonorrhea)?
48. Kidney, bladder disease?
49. Thyroid, adrenal disease?
51. Psychiatric care?
52. Radiation treatments?
54. Prosthetic heart valve?
55. Artificial joint?
57. Blood transfusions?
60. Contact lenses?
61. Recreational drugs?
62. Drugs, medications, over-the-counter medicines (including Aspirin), natural remedies?
63. Tobacco in any form?
65. Are you or could you be pregnant or nursing?
66. Taking birth control pills?
67. Do you have or have you had any other diseases or medical problems NOT listed on this form?
If so, please explain:
To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.
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