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 Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
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)?
*
Please Select
Yes
No
Have you had difficulty with veins being found during blood tests or a history of difficult veins?
*
Please Select
Yes
No
Sometimes
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
Back
Next
Please answer the following questions with regard to undergoing dental treatment.
If you went to your Dentist for TREATMENT TOMORROW, how would you feel?
*
Please Select
Not anxious
Slightly Anxious
Fairly Anxious
Very Anxious
Extremely Anxious
If you were sitting in the WAITING ROOM (waiting for treatment), how would you feel?
*
Please Select
Not anxious
Slightly Anxious
Fairly Anxious
Very Anxious
Extremely Anxious
If you were about to have a TOOTH DRILLED, how would you feel?
*
Please Select
Not anxious
Slightly Anxious
Fairly Anxious
Very Anxious
Extremely Anxious
If you were about to have your TEETH SCALED AND POLISHED, how would you feel?
*
Please Select
Not anxious
Slightly Anxious
Fairly Anxious
Very Anxious
Extremely Anxious
If you were about to have a LOCAL ANESTHETIC INJECTION in your gum, above an upper back tooth, how would you feel?
*
Please Select
Not anxious
Slightly Anxious
Fairly Anxious
Very Anxious
Extremely Anxious
MDAS Score
5-10 Low, 11-18 Moderate, >19 High Anxiety
Obstructive Sleep Apnea Risk
BMI
MDAS Score
Submit
©2024 by Rohit Bedi
Target Controlled Infusions
www.rohitbedi.co.nz
Should be Empty: