Procedural Sedation Record
Patient Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Birth Date
*
-
Month
-
Day
Year
Date
Weight (lbs):
*
Height (feet/inches):
*
in Feet/Inches
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Emergency Contact Email
*
example@example.com
Have you had any issues with anesthesia before? If yes, please describe:
Medical Questionnaire
Yes
No
Heart surgery, disease, attack?
Blood transfusion?
Heart murmur?
Hemophilia or blood disorder?
Mitral valve prolapse?
Hepatitis A, B?
Heart attack or strokes?
Lung disease (Emphysema, Asthma, Tuberculosis)?
Artificial Heart Valve/ Pacemaker?
Tumors?
Heart pacemaker?
Headaches or migraines?
Convulsions or epilepsy?
Neurological disorders?
Dizzy spells or fainting?
Diabetes?
Thyroid disorder?
Kidney disease?
Stomach, intestinal, or colon disorders?
Jaundice or liver disease?
Cortisone or steroid therapy?
High blood pressure?
Possess the HIV or AIDS antibody?
Low blood pressure?
Psychiatric or psychological care?
Cancer?
Allergies?
Radiation or Chemotherapy?
Bruise easily?
Emphysema or asthma?
Do you have any other disease/condition not listed above? What treatment have you received for the condition listed above?
Do you take anticoagulants?
Yes
No
If yes, what are they and what are they used for specifically?
Do you use recreational drugs?
Yes
No
Have you ever smoked or used tobacco products?
Yes
No
Do you or have you ever smoked or used tobacco? Please describe type, frequency and duration
If you did smoke, when did you quit?
-
Month
-
Day
Year
Date
Are you currently pregnant or trying to become pregnant?
Yes
No
I, the above-named patient, understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Dental care has my permission to ask the respective health care provider or agency, who may release such information. I will notify this dental care facility of any and all changes in my health or medications. I consent to the performing of dental procedures agreed to be necessary or advisable, including the use of local anesthetics.
Signature
Date
Submit
Should be Empty: