Pre-sedation Screening

Pre-sedation Screen

Please fill out the following questions to the best of your ability. This will enable us to streamline your care for your upcoming procedure(s).
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

DayMonthYear
Height (cm)
Weight (Kg)
Do you have ANY health conditions that the sedationist/dentist should be aware of? If yes please list these below.
Please list ALL your current medications that you are taking (including vitamins or supplements).
Please list ANY allergies (including food).
Do you snore loudly in your sleep (loud enough to be heard through closed doors or your partner elbows you for snoring at night)?*
Have you had difficulty with veins being found during blood tests or a history of difficult veins?*
Is there anything else you would like to discuss with your sedationist/dentist regarding your upcoming sedation procedure?
Escort after procedure
Contact number for escort
©2024 by Rohit Bedi Target Controlled Infusions www.rohitbedi.co.nz

Please answer the following questions with regard to undergoing dental treatment.
If you went to your Dentist for TREATMENT TOMORROW, how would you feel?*
If you were sitting in the WAITING ROOM (waiting for treatment), how would you feel?*
If you were about to have a TOOTH DRILLED, how would you feel?*
If you were about to have your TEETH SCALED AND POLISHED, how would you feel?*
If you were about to have a LOCAL ANESTHETIC INJECTION in your gum, above an upper back tooth, how would you feel?*
MDAS Score
5-10 Low, 11-18 Moderate, >19 High Anxiety
Obstructive Sleep Apnea Risk
BMI
MDAS Score
Should be Empty:

Pre-sedation Screen