Patient Name *

Email *

Consult Date *

Date of birth *

Age *

Family Doctor's Name *

Medical Specialist Name: (if applicable)

Have you ever received General Anesthesia? *

Yes

If yes, when and were there any complications:

Have you OR any members of your family had an adverse reaction to an anesthetic? *

Yes

What was the reaction? (Ex. Malignant Hyperthermia, Pseudocholinesterase deficiency)

Are you being treated for any medical conditions, present or within the past year? *

Yes

If yes, please explain:

Are you taking any prescription medications that belong to the following drug categories:

GLP-1 (Ozempic, Wegovy, Mounjaro, Semaglutide, Tirzepatide, Retatrutide) *

Yes

Please specify:

ACE inhibitors (Lisinopril, Ramipril, Enalapril) *

Yes

Please specify:

Blood thinners (Apixaban, Rivaroxaban, Warfarin) *

Yes

Please specify:

Injectable Peptides *

Yes

Please specify:

Are you taking any other prescription medications, non-prescription drugs, vitamins or supplements? *

Yes

If yes, please list:

Have you ever had an adverse reaction to any medication? *

Yes

If yes, explain:

Do you have any allergies? *

Yes

Medications

Latex/Rubber

Other

Do you use cannabis or any other recreational drugs? *

Yes

If yes, what drug(s) and how often?

Do you have high blood pressure?

Yes

Do you have cardiovascular disease? *

Yes

Please explain:

Do you have a bleeding/clotting disorder? *

Yes

Please provide more details:

Do you have asthma? *

Yes

How often do you use an inhaler?

Have you ever been hospitalized for your asthma?

Do you have a prosthetic or artificial joint? *

Yes

Do you require prophylactic antibiotics?

Yes

If yes, please provide details:

Do you have a history of snoring or sleep apnea? *

Yes

If yes, do you use a CPAP machine?

Do you wear contact lenses? *

Yes

Do you or have you had any of the following conditions? *

ADHD

AIDS/HIV

Angina

Anxiety Disorder

Arthritis

Asthma/COPD

Autism

Cancer

Depression

Diabetes

Drug/Alcohol Dependency

Fainting Spells

Heart Attack

Heart Murmur

Hepatitis

Kidney Disease

Lung Disease

Mitral Valve Prolapse

Needle-phobic

Osteoporosis

Pacemaker

Panic Attack

Rheumatic Fever

Seizures

Shortness of Breath

Steroid Therapy

Stomach Ulcers

Stroke

Thyroid Disease

Tuberculosis

Are you anxious during dental treatment? *

Yes

If yes, rate your dental anxiety (1=low, 5=high)

What type of sedation are you most interested in receiving for your dental treatment? *

IV Conscious Sedation

General Anesthesia

Are you pregnant, trying to get pregnant or nursing? *

Yes

NOTE: IT IS IMPORTANT THAT ANY CHANGES IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE.

I, the undersigned, certify that all the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my primary physician or my pharmacy being contacted if necessary to obtain information that is required for my dental care.

Patient Signature *

Clear

Date *