Anesthesia Questionnaire

Pre-Anesthesia Medical Questionnaire

& Disclosures
Date*

MonthDayYear
Date
Is the patient himself / herself filling this form?*

YESNO
Patient Name*

First NameLast Name
Date of Birth (mm/dd/yyyy)*
Sex*

MaleFemale
If this form is NOT filled by the patient please type in the name of parent or guardian that filled the form with the knowledge or presence of the patient.

Full Name Relationship to the patient
Medicare Opt-out Disclosure:

Dear Patients / Parents / Legal Guardians,

This paragraph is a disclosure to inform you that Dr. Reza Izadi has opted out of Medicare.

Therefore any anesthesiology services provides to you by Dr Izadi and Advanced Dental Anesthesia PLLC aka Safe Dental Sedation are not covered by Medicare, Medicaid or any other insurance plans or insurance companies. Medicare and Medicaid payments are not accepted. As a result, Medicare or insurance companies will not reimburse you by Dr Izadi for any services provided. If you choose to receive care from me or Advanced Dental Anesthesia PLLC and Dr Izadi you will be responsible for the full payment of my services payable to your dental office. You will need to enter into a private contract with your dental office, as required by Medicare regulations, which confirms your understanding and agreement to these terms. If you seek reimburement for the anesthesia services from your insurance company that is between you and the insuramce company. Advamced Please enter your name below to agree with the terms in this disclosure and sign in the field below it.
I have read and understand the Medicare Disclosure above:

First NameLast Name
Signature

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Dental office Performing the Procedure and/or Dentist (Be Specific Please / NOT your referring dental office)*
What procedure are you having done?*

Full Mouth Reconstruction (Implants, Crowns)Root CanalTeeth ExtractionsSimple Cosmetic / CleaningOther
Date of Procedure (mm/dd) or TBD*
Email*
example@example.com
Cell Phone (A number we can text) *
Please enter a valid phone number.
Telehealth Texts

Please expect Tele-health texts from us that will look like the image below from “ Dr Reza Izadi”. When they arrive you must consent to view the important content. Please do not ignore. Thank you
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Medical section

Please be as comprehensive as possible.
Age *
Please enter your weight in Pounds and height *
How many alcoholic drinks do you consume per week*

None5 or less per week6-10 per weekMore than 10 per week
Which of the following describe your smoking habits*

Non-smokerSmoke less than a pack per weekAbout a pack per weekMore than a pack per weekAbout a pack per dayVaping or e-cigs
Do you smoke marijuana?*

YesNo
Do you exercise*

YesNo
Are you able to go up 1 flight of stairs ?*

YesNo
Are you able to walk 2 blocks without Shortness of breath or chest pain - if not please write what limits you such as pain due to arthritis under section “other”.*

YesNoI use a cane or a walkerOther
Please list all ALLERGIES to medications and foods *
Please let us know if you are taking any of the following Medications:

Invokana (Canagliflozin)Farxiga, Xigduo, Qtern (Dapagliflozin)Jardiance, Synjardy, Glyxambi (Empagliflozin)Stoglatro, Seglurome (Ertugliflozin)—-Ozempic, Rybelsus, Wegovy (Semaglutide)Trulicity (Dulaglutide)Mounjaro, Zepbound (Tirzepatide)Tamzeum (Albiglutide)Victoza, Saxenda (Liraglutide)Adkyxin, Soliqua (Lixisenatide)Byetta, Bydureon (Exenatide)—-PhentermineSuboxone, Bunavail, Zubsolv (Buprenorphine/Naloxone)BuprenorphineMethadone
Please type in all medications and inhalers you are taking not listed above ; Please write in NONE if that is the case ( DO NOT include doses or frequency ) *
Please list any major surgeries or recent surgeries
List any issues with Anesthesia or surgeries in the past*

Never had anesthesiaNONE - No issuesNausea / VomitingDifficult airway / Or difficult IntubationDifficult IV accessSelf or family history of Malignant HyperthermiaPseudocholinesterase DeficiencyOther
Do you have a history of Nasal bleeds (If Yes please elaborate) :
If you need to add anything on problems with anesthesia or if you are a difficult IV access please do so below. Let us know if you have had to get a PICC line before as IV access.
Please note under any section below you may select “Other” and a space will appear for you to write in your additional input.
Please describe your COVID status:*

Have been fully vaccinatedPartially VaccinatedHad COVID infectionOther
List any Ear / Nose / Throat illness*

NoneHistory of Motion SicknessSeasonal allergiesSjogren syndromeChronic vertigoDeviated septumMeniere’s DiseaseOther
Endocrine or hormonal*

NoneDiabetes type 1 (Juvenile onset)Diabetes type 2 - not on InsulinDiabetes type 2 - on InsulinHyperthyroidismHypothyroidismOther
List and Respiratory illness*

NoneObstructive Sleep ApneaAsthmaCOPD / Emphysema / Chronic BronchitisPulmonary (Lungs) HypertensionOther
List any Cardiovascular diseases*

NONEHypertension ( High Blood Pressure)High cholesterolHeart Disease (Coronary artery disease) Or History of a history of MI ( Heart attack )Congestive Heart DiseasePeripheral Vascular DiseaseAtrial FibrillationPacemaker or DefibrillatorAortic Artery AneurysmCoarctation of AortaAortic Stenosis or RegurgitationMitral Valve Disease (elaborate under other below)WPWOther Arrhythmias - explain under “other“ belowPOTS DysautonomiaOther
If you have had previous heart attack please tell us how it was treated

Treated with medicationStentsBypass surgeryBallon AngioplastyOther
How is your heart now

GoodOkI get chest pain when I exert myselfI get chest pain at restOther
Approximate time of last cardiology visit and recommendation
Approximate time of last Stress test
Approximate time of last Echocardiogram ( Heart Ultrasound)
List any neurological illness, if any positive in the field below write in dates and condition now.*

NoneMigrainesMini-stroke or TIA (Transient Ischemic Attack)StrokeSeizure disorderAlzheimer’sParkinson’sBrain AneurysmMyasthenia GravisDiabetic NeuropathyOther
Any residual or limitations after stroke?
Behavioral / Psychiatric*

NoneDepressionAnxietyBipolar DisorderSchizophreniaADD / ADHDPTSDCerebral PalsyAutismDown’s SyndromeOther
Gastrointestinal*

NoneGERD or acid refluxGastritis / UlcersIrritable bowl syndromeUlcerative colitis / Chron’s diseaseHepatitis COther hepatitisFatty LiverOther
Urinary / Kidneys / Bladder*

NoneBPHKidney stonesKidney (Renal) insufficiencyOther
Blood Disorders*

NoneHistory excessive BleedingHistory excessive ClottingHistory of blood clots or emboliG6PD deficiencyAnemiaMyelodysplastic syndromeOther
Muskoloskeletal / Dermatological*

NoneOsteoarthritisRheumatoid ArthritisChronic Back PainPinched nerve in back or neckHistory of Cervical spine (Neck) fusionPsoriasisEczemaOther
Do you have radiculopathy from the never pain or shooting pain? Please explain where ( for example “sciatica with pain down my legs”)
Any other medical disorders*

NonePOTS DysautonomiaHIVAny other autoimmune disorder not listedSystemic lupus ErythematousPrevious Cancer (Elaborate under other)History of radiation (Elaborate under other)Chronic pain of any kindOther
Anything you would like to add or not listed
If you have a Primary Care Physician (PCP) or other specialists please provide their names and office numbers below:

( NOT YOUR DENTISTS )
PCP Name (Physician Not Dentist)

First NameLast Name
PCP Phone Number
Please enter a valid phone number.
Name & Specialty

Full Name Specialty
Specialist Phone Number
Please enter a valid phone number.
Name & Specialty

Full Name Specialty
Specialist Phone Number
Please enter a valid phone number.
By signing below I attest that I am the patient above and I filled this form in its entirely: *

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By signing below I attest that I am the person whose name I printed in this form. I also attest that I am either the legal custodian of the patient or filling out this form with knowledge and presence of the patient:*

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Should be Empty:

Pre-Anesthesia Medical Questionnaire

Telehealth Texts

Medical section

Please note under any section below you may select “Other” and a space will appear for you to write in your additional input.

If you have a Primary Care Physician (PCP) or other specialists please provide their names and office numbers below: