Patient Forms (Please complete form upon request of the office manager.) PATIENT INFORMATION Title:Mr.Mrs.MissMs. Marital Status:SingleMarriedOther Birth Date: Gender: Male Female State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming Last Visit Date: SPOUSE INFORMATION PERSON RESPONSIBLE FOR ACCOUNT Same as Above?YesNo EMERGENCY CONTACT DENTAL HISTORY Are you currently in Pain?YesNo Your current Dental Health is: Choose: Good Fair Poor Toothbrush bristles type: Choose: Hard Medium Soft Do you floss daily? YesNo Have you lost any teeth? YesNo Toothbrush type: Choose: Manual Electric How long do you use a toothbrush before replacing? What other oral products do you use? Do you require antibiotics before dental work? YesNo Do your gums ever bleed?YesNo Have you ever had periodontal disease? YesNo Does food get caught between your teeth? YesNo Are your teeth sensitive to hot, cold, other? YesNo Are you happy with the way your smile looks? YesNo MEDICAL HISTORY Do you have a personal physician?YesNo Last visit date: Please List Any Allergies Have you experienced any of the following? Abdominal Bleeding YesNo Frequent or Severe Headaches YesNo Radiation Treatment YesNo Alcohol Use YesNo Glaucoma YesNo Rheumatic Fever YesNo Anemia YesNo Hay Fever YesNo Scarlet Fever YesNo Arthritis YesNo Heart Murmur / Defect YesNo Seizures YesNo Artificial Bones / Joints YesNo Hepatitis YesNo Sinus Problems YesNo Artificial Valves YesNo High Blood Pressure YesNo Sleep Apnea Diagnosis YesNo Asthma YesNo HIV+ / AIDS YesNo Snoring YesNo Bleeding Disorder YesNo Impaired Cognition(difficulty concentrating or thinking) YesNo Steroid Therapy YesNo Blood Transfusion YesNo Insomnia YesNo Stroke YesNo Cancer YesNo Ischemic Heart Disease (Coronary Artery Disease/Atherosclerosis) YesNo Taken: Phen-Phen or Redux YesNo Chemotherapy YesNo Kidney Problems / Desease YesNo Tobacco Use: YesNo Colitis YesNo Latex allergy YesNo Tuberculosis (TB) YesNo Congenital Heart Disease YesNo Liver Disease YesNo Ulcers YesNo Daytime Sleepiness / Fatigue YesNo Low Blood Pressure YesNo Venereal Disease YesNo Drug Abuse YesNo Mood Disorders / Depression YesNo Diabetes YesNo Emphysema YesNo Osteoporosis YesNo Metal Allergy YesNo Fainting Spells YesNo Pacemaker YesNo Difficulty Breathing YesNo Fever Blisters / Herpes YesNo Persistent Cough YesNo Mitral Valve Prolapse YesNo Recreational Drug Use YesNo For Women: Are you taking birth control pills? YesNo Are you pregnant? YesNo Are you nursing? YesNo Please list any past surgery/injuries/hospitalizations that are not listed above Please list any medications that you are taking If you have a written or typed list you may leave this blank (Please include regularly used over-the-counter medications and nutritional supplements) COMMUNICABALE DISEASE CONTROL DISCLAIMER Our Policy and procedure dictated to us by the Nevada Dental Board of Examiners is as follows: if we during treatment find that there are signs of a communicable disease (i.e. Cold or Flu), we have to delay treatment until medical clearance has been obtained from a licensed physician. Date: I affirm that the above information is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes. I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover. I understand that I am responsible for all amounts that my insurance doesn’t cover. Payment is due in full at the time services are rendered unless prior arrangements have been approved. Date: Thank you for filling out these forms completely. If you have any questions at any time, please ask us. Our office is HIPPA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA. RECORDS RELEASE REQUEST If you have x-rays from a previous dentist please fill out this form Date: Requesting Records From: Requesting Doctors practice: Celeste M Eckerman D.D.S. (775)782-2799. Email: firstname.lastname@example.org I authorize the release of dental Records and Medicals records relevant to dental treatment, or copies of such, and request that they be transferred. 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