Medical Sedation History

Step 1 of 4

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Personal Information

Name*

Prefix First Middle Last

Sex*

Male

Female

Date of Birth*

DD slash MM slash YYYY

Address*

Street Address Address Line 2 City Province Postal Code

Cell Phone*

Home Phone

Work Phone

Email*

Emegency Contact

Name*

First Last

Relationship to you*

Phone*

(If Applicable) Parent or legally authorized representative

Name

First Last

Family Doctor

Name*

Phone*

(If Applicable) Medical Specialist

Name

Phone

Medical Questionnaire

Have you ever had minimal or moderate sedation?*

Yes

Approximately When?*

If you had any complications please explain

Have you ever had complications following a dental treatment?*

Yes

Please Explain*

Do you have any history of familial sedation/anaesthetic complications?*

Yes

Please Explain*

Are you or have you even been treated for a serious medical condition?*

Yes

Please Explain*

Have you had a medical examination in the last year?*

Yes

Approximately when was your last medical examination?*

Are you currently being treated or have you been treated in the past year?*

Yes

Has there been any change in your general health in the past year?*

Yes

Please Explain*

Are you taking any medications, prescription drugs or herbal supplements of any kind?*

Yes

Please List*

Do you have any allergies?*

Yes

If yes please list

Medications

Have you ever had a peculiar or adverse reaction to any medications?*

Yes

If yes please explain

Peculiar/Adverse Reactions

Latex/Rubber Products*

Yes

Other

Do you or have you ever had asthma?*

Yes

Do you have or have you ever had any heart or blood pressure problems?*

Yes

Do you or have you ever had a replacement or repair of a heart valve, an infection of the heart (eg infective endocarditis), a heart condition from birth (eg congenital heart disease) or a heart transplant?*

Yes

Please Explain*

Do you have a prosthetic or artificial joint?*

Yes

Please Explain*

Do you have any conditions or therapies that could affect your immune system (eg leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

Yes

Please Explain*

Have you ever had hepatitis, jaundice or liver disease?*

Yes

Please Explain*

Do you have a bleeding problem or bleeding disorder?*

Yes

Please Explain*

Have you ever been hospitalized for any illnesses or operations? (In the past 5 years)*

Yes

Please Explain*

Do you have or have you ever had any of the following? Please check all that apply.

Arthritis*

Yes

Cancer*

Yes

Chest Pain, Angina*

Yes

Drug/Alcohol Dependency*

Yes

Heart Attack*

Yes

Kidney Disease*

Yes

Lung Disease*

Yes

Mitral Valve Prolapse*

Yes

Osteoporosis Medications (E.G., Fosamax, Actonel)*

Yes

Pacemaker*

Yes

Rheumatic Fever*

Yes

Seizures (Epilepsy)*

Yes

Steroid Therapy*

Yes

Shortness Of Breath*

Yes

Stroke*

Yes

Stomach Ulcers*

Yes

Thyroid Disease*

Yes

Tuberculosis*

Yes

Do you have any other conditions, diseases, allergies or health issues we should be aware of?

Please list

Are there any diseases or medical problems that run in your family?

Please list

Do you smoke or chew tobacco?*

Yes

Have you ever received treatment for drugs or alcohol?*

Yes

Are you nervous during dental treatments?*

Yes

Is there any problem or medical condition that you wish to discuss in private only?*

Yes

Women Only

Are you pregnant or suspect you might be?*

Yes

What is your anticipated delivery date?*

DD slash MM slash YYYY

Are you breast feeding?*

Yes

Are you taking any birth control pills?*

Yes

Which brand?

NOTE: IT IS IMPORTANT THAT ANY CHANGES IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE

I, the undersigned, certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician being contacted if necessary to obtain information that is required for my dental care.

Signature

Patient

Parent

Legally Authorized Representative

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