Patient IV Screening Form

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. Please fill in the entire form

Your Height: * Your Weight: * (must fill both in)

Person to notify in case of Emergency: * Relationship: * Phone number: *

Who is your ride? * Phone Number: *

What is your Blood Pressure? (Can be taken at any Shoppers Drug Mart, if you would prefer please contact our office so we can see you for a blood pressure in house) ***Example- 120/80

1. Have you every had minimal or moderate sedation?*

YesNo

2. Any Complications?

YesNo

If yes please describe: (Was there sickness following sedation?)

3. Are you being treated for any medical condition at the present or within the past year?

YesNo

If yes please explain:

4. When was your last medical check-up?*

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

YesNo

If yes, please explain:

6. Are you taking any medications, non-prescription drugs, recreational drugs, herbal supplements of any kind? (***PLEASE answer honestly, some recreational drugs can have SEVERE and/or ADVERSE REACTIONS, INCLUDING DEATH, if mixed with sedation medications)

YesNo

Do you use marijuana/cannabis

YesNo

If Yes, how often do you use marijuana cannabis?

List Medications Here: (If uploading please state so in the box below, or the form will not let you move on to the next page)

Upload medications lists here:

Patient IV Screening Form

Patient Medical History

Medical History Questionnaire