MEDICAL HISTORY QUESTIONNAIRE FOR IV SEDATION
Dr Firoz Vellani MBBS(Syd)
Date
/
Month
/
Day
Year
Date
Name:
Phone Number:
Address:
Date of Birth:
/
Month
/
Day
Year
Date
Gender:
female
male
Height:
Weight:
Email Address:
example@example.com
Occupation:
PLEASE PROVIDE INFORMATION ABOUT THE FOLLOWING:
Rows
No
Yes
Further Information /Explain
List Any previous operations/procedures. When and Why?
1
2
Previous Anaesthetic problems/adverse events/reactions?
3
4
Any current or previous medical conditions?
If Yes give further details
5
6
Specifically, is there any history of the following:
Rows
Please select
Asthma
7
Shortness of Breath
8
Cough
9
Chronic Bronchitis
10
Lung Disease
11
Snoring
12
Sleep Apnoea
13
Stomach Ulcer
14
Reflux(GORD)
15
Hiatus Hernia
16
Liver/ Hepatitis(Any)
17
Diabetes
18
Thyroid Problems
19
Arthritis/Artificial Joints
20
Glaucoma
21
Angina / Heart Attack
22
Heart Surgery/Stents
23
Heart Trouble
24
Heart Murmur
25
Rheumatic Fever
26
High Blood Pressure
27
Low Blood Pressure
28
Arrhythmia(Any Type)
29
Palpitations
30
Vascular Problems
31
Hay Fever
32
Sinus Trouble
33
Cancer
34
Cancer Treatment
35
Live Alone?
36
Stroke (CVA, TIA)
37
Epilepsy/Fits
38
Fainting/Vertigo
39
Balance/Walking Issue
40
Migraine
41
Renal Disease
42
Urological Disease
43
Anaemia
44
Blood Disorders
45
Depression/Anxiety
46
ADHD
47
Psychiatric Treatment
48
Ilicit Drug Use (Any)
49
Recreational Drug Use
50
Any Other Conditions
51
Further information of any previous or current medical conditions?
Are you taking any regular medications?
Yes
No
Please list medications, with doses. (including vitamins, herbal treatments, etc).
Do you have any allergies?
Yes
No
If Yes please list:
Are you pregnant or breastfeeding?
Yes
No
Do you smoke? (cigs, vaping, marijuana, etc)
Yes
No
If Yes How many per day?
Do you drink alcohol?
Yes
No
If Yes how much per week?
Are You anxious/phobic about dentistry?
Yes
No
If yes, Please choose how much:
Slight
Moderate
Extremely
is there anything else about your health that we should know?
Yes
No
If Yes please explain?
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