Medical Questionnaire

SEDATION TEAM

CONFIDENTIAL MEDICAL HISTORY
Please complete this form so that we can provide you with safe and comfortable
treatment.

It is important to include all information requested. If you withhold
information, you may put yourself at unnecessary risk.

Please use the additional space after each questions to provide any more details.
PERSONAL INFORMATION
Patient Name*

First NameLast Name
MaleFemale
Date of birth

DayMonthYear
Phone contact details
PhoneEmail
Occupation
DENTAL AND MEDICAL HISTORY
Name of last dentist:
When did you last receive dental treatment?
Doctors name:
Doctors surgery:
Doctors phone number:
ExcellentGoodFairPoor
YesNo
If yes, please provide details:
MEDICATIONS
Please list any medications you are currently taking, includingany prescribed, herbal or recreational medications
SEDATION HISTORY
YesNo
TabletGas and airInjection in hand/armOther
If yes, what was this for?
YesNo
If yes, what was this for?
Is there any family history of problems with sedation? If yes, please detail:
HEART

Have you ever had any of the following:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
BLOOD

Have you ever had any of the following:
YesNo
YesNo
YesNo
YesNo
YesNo
CHEST

Have you ever had any of the following:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
OTHER

Have you ever had any of the following:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
ALLERGIES
YesNo
YesNo
Have you taken any steroid medication in the last two years? If yes, details:
SOCIAL HISTORY
YesNo
YesNo
YesNo
How many units of alcohol do you drink a week?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Please complete the following questionnaire:
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious
Please circle how you are feeling today:
Please sign and date

Clear
Date

DayMonthYear
Should be Empty:

SEDATION TEAM

PERSONAL INFORMATION

DENTAL AND MEDICAL HISTORY

MEDICATIONS

SEDATION HISTORY

HEART

BLOOD

CHEST

OTHER

ALLERGIES

SOCIAL HISTORY

Please complete the following questionnaire: