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Dental Practices
Dental Sedation: Medical History Form
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Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Date of Birth
*
Email
*
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Mobile Phone:
*
10 digit mobile phone number
Female / Male
*
Female
Male
Weight (kg)
*
Weight in KG
Height (metres)
*
Height in metres
BMI
BMI will be calculated based on Weight and Height
Do you currently, or have you previously suffered from any of the following conditions?
Stroke
*
Yes
No
Shortness of breath
*
Yes
No
Chest pain
*
Yes
No
Palpitations
*
Yes
No
Rheumatic fever
*
Yes
No
Heart attack
*
Yes
No
High blood pressure
*
Yes
No
Asthma
*
Yes
No
Persistent cough
*
Yes
No
Other lung diseases
*
Yes
No
Anaemia
*
Yes
No
Diabetes
*
Yes
No
Bleeding disorder
*
Yes
No
Kidney / Liver problems
*
Yes
No
Thyroid problems
*
Yes
No
Indigestion or heartburn
*
Yes
No
Stomach ulcers
*
Yes
No
Epilepsy / fitting
*
Yes
No
Dizziness
*
Yes
No
Arthritis
*
Yes
No
Infections diseases: HIV, Hep B, Hep C or other
*
Yes
No
Cancer
*
Yes
No
Have you had anaesthetics before?
*
Yes
No
Please describe your previous experiences with anaesthetics
*
Do you smoke or vape?
*
Yes
No
How many cigarettes / vapes per day
*
Do you suffer from any allergies?
*
Yes
No
Please describe your allergies
*
Are you pregnant?
*
Yes
No
Please list the medications you are currently taking. Including any over the counter medication, vitamins or contraceptive pills
Name, Strength and Dose
Name, Strength and Dose 2
Name, Strength and Dose 3
Name, Strength and Dose 4
Name, Strength and Dose 5
Name, Strength and Dose 6
Name, Strength and Dose 7
Name, Strength and Dose 8
Name, Strength and Dose 9
Name, Strength and Dose 10
Submit
