Dental Anesthesia Intake Form/Health History

Dental Anesthesia Intake Form/Health History
Client Information

Red asterisk (*) indicates required field.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Height (In feet.inches; Example 5.9 is 5 feet 9 inches)*
Weight (In pounds. Please use actual weight. This is very important for anesthesia)*
Gender Assigned at Birth*

FemaleMalePrefer not to say
Contact Information
Phone Number*
Email
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts
Medical History
Current Medications. If none, then state 'none'.*
Drug Allergies*

NO KNOWN DRUG ALLERGIES (NKDA)Acetaminophen (i.e. Tylenol)Aspirin/Ibuprofin/NSAIDSBenzodiazepine (diazepam/Valium, midazolam/Versed, lorazepam/Ativan)CodeineFentanylLatexLocal anesthetic (lidocaine/xylocain, Marcaine/bupivicaine, etc.)PenicillinPercocetPropofolSulphaOther (please list below)
Other Medication Allergies
Do you have any of the following conditions?

AlcoholismAllergies, seasonalAnemiaAnxiety/panic disorderArtificial heart valveAsthmaAutoimmune disorder (other than Rheumatoid Arthritis)Blood diseaseBruise easily/bleeding disorder/on anti-coagulants or "blood thinners"CancerChemotherapyCOPD/Emphysema/chronic bronchitisDiabetesDown's SyndromeDrug addiction (please explain below)GERD/reflux/hiatal hernia/frequent "heart burn"Heart conditionsHigh blood pressure/HypertensionHIV/AIDSKidney diseaseLiver Disease/hepatitis/cirrhosisNeurologic disorder/disease (Parkinson's, MS, etc.)Obstructive Sleep Apnea (OSA)PregnantPTSD (Post-Traumatic Stress Disorder)Rheumatoid ArthritisSeizure DisorderThyroid disorder
Other medical conditions not otherwise discussed
Do you smoke or chew tobacco?*

YesNoFormer
How many packs a day?*
What year did you quit?*
How many years have you smoked or chewed, including past use?*
Do you use THC/Marijuana?*

YesNo
Tetrahydrocannabinol (THC) use is associated with increased risk of cardiovascular complications under anesthesia, particularly non-occlusive coronary events such as myocardial infarction (Heart attack) and coronary vasospasm. Within the first hour after cannabis consumption, patients face a 4.8-fold increased risk of myocardial infarction compared to periods of non-use.[2] This elevated risk appears to decline rapidly after the first hour, with relative risk dropping to 1.7 in the second hour.[2] However, Cannabis use increases risk of heart attack and stroke if consumed by smoking, vaping, edibles or other forms. Current guidelines recommend discontinuing ANY cannabis/THC use 7 days prior to any planned anesthetic, longer if possible.

1.Perioperative Care of Cannabis Users: A Comprehensive Review of Pharmacological and Anesthetic Considerations.

Echeverria-Villalobos M, Todeschini AB, Stoicea N, et al. Journal of Clinical Anesthesia. 2019;57:41-49. doi:10.1016/j.jclinane.2019.03.011.

2.ASRA Pain Medicine Consensus Guidelines on the Management of the Perioperative Patient on Cannabis and Cannabinoids.

Shah S, Schwenk ES, Sondekoppam RV, et al.Regional Anesthesia and Pain Medicine. 2023;48(3):97-117. doi:10.1136/rapm-2022-104013.
Do you consume alcohol?*

NeverOccasionalSocialModerate (1-2 drinks/day for men; 1 drink/day for women)Heavy (15+ drinks/week for men; 8 drinks/week for women)
Surgical History
Please list all surgeries and dates of surgeries
STOP-BANG

Questions for Obstructive Sleep Apnea (OSA) risk
Snore - Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?*

YesNo
Tired - Do you often feel tired, fatigued, or sleepy during the daytime?*

YesNo
Observed - Has anyone observed you stop breathing during your sleep?*

YesNo
Blood Pressure - Do you have or are you being treated for high blood pressure? Do you take blood pressure medication for high blood pressure/hypertension?*

YesNo
BMI - Is your body mass index (BMI) greater than 35 kg/m²?*

YesNoI don't know
Age - Are you 50 years or older?*

YesNo
Neck Circumference - Is your neck circumference greater than 40 cm (16 inches)?*

Yes (Males: Large shirt neck size; Females: Extra large shirt neck size)No
Gender - Male at birth?*

YesNo
Score 1 point for each "Yes" answer.

Risk Stratification
- 0–2 = Low risk of obstructive sleep apnea (OSA)
- 3–4 = Moderate risk of OSA
- 5–8 = High risk of OSA
If you score a 5 or more and are not currently under supervision by your doctor for Obstructive Sleep Apnea (OSA), please schedule an appointment with them to discuss this finding.
Referring Dentist/Dental Office
Your Dentist*

Dr. Ryan Helgerson, DMDDr. Heidi West, DMDOther
Referring Dental Office*

Bookcliff Family DentalOther
Proposed Dental Procedure Date (Anesthesia Date)*

MonthDayYear
Date
Anesthesia History
Have you ever had sedation or anesthesia before?*

YesNo
Any problems with anesthesia?*

NoNausea/VomitingDifficulty breathingAwareness under anesthesiaOther
If "Other", please explain.
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Dental Anesthesia Intake Form/Health History

Client Information

Contact Information

Emergency Contacts

Medical History

Surgical History

STOP-BANG

Questions for Obstructive Sleep Apnea (OSA) risk

Referring Dentist/Dental Office

Anesthesia History