• Dental Anesthesia Intake Form/Health History

  • Client Information

    Red asterisk (*) indicates required field.

  • Date of Birth*
     - -
  • Gender Assigned at Birth*

  • Contact Information

  • Emergency Contacts

  • Medical History

  • Drug Allergies*
  • Do you have any of the following conditions?
  • Do you smoke or chew tobacco?*
  • Do you use THC/Marijuana?*

  • 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?*

  • Surgical History

  • 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)?*
  • Tired - Do you often feel tired, fatigued, or sleepy during the daytime?*
  • Observed - Has anyone observed you stop breathing during your sleep?*
  • 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?*
  • BMI - Is your body mass index (BMI) greater than 35 kg/m²?*
  • Age - Are you 50 years or older?*
  • Neck Circumference - Is your neck circumference greater than 40 cm (16 inches)?*
  • Gender - Male at birth?*

  • 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*
  • Referring Dental Office*
  • Proposed Dental Procedure Date (Anesthesia Date)*
     - -

  • Anesthesia History

  • Have you ever had sedation or anesthesia before?*
  • Any problems with anesthesia?*
  • Today's Date*
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  • Should be Empty: