PATIENT MEDICAL HISTORY

As per regulatory guidelines in Alberta, we are unable to sedate patients with a BMI over 40 in a general dentist office.

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. Please fill in the entire form

MEDICAL HISTORY QUESTIONNAIRE

Have you ever had minimal or moderate sedation *

Yes

No

Any complications

Yes

No

Describe complications

Are you being treated for any medical condition at the present or within the past year *

Yes

No

If yes, please explain condition

When was your last medical check-up *

Has there been any change in your general health in the past year *

Yes

No

If yes, please explain change

Are you taking any medications, non-prescription drugs or herbal supplements of any kind *

Yes

No

If yes, please list

Do you have any allergies *

Yes

No

If yes, please list using the categories below:

a. Medications

b. Latex, rubber products

c. Other e.g. hay fever, foods

Have you ever had a peculiar or adverse reaction to any medicines or injections *

Yes

No

If yes, please explain reaction

Do you have asthma *

Yes

No

a. How often do you use an inhaler

b. Have you ever been hospitalized for your asthma

Do you have or have you ever had any heart or blood pressure problems *

Yes

No

If yes, please explain:

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart, e.g. infective endocarditis, a heart condition from birth, e.g. congenital heart disease, or a heart transplant *

Yes

No

If yes, please explain below

Do you have a prosthetic or artificial joint *

Yes

No

Do you have any conditions or therapies that could affect your immune system, e.g., leukemia, AIDS, HIV infection, radiotherapy, chemotherapy *

Yes

No

If yes, please explain

Have you ever had hepatitis, jaundice or liver disease *

Yes

No

If yes, please explain

Do you have a bleeding problem or bleeding disorder *

Yes

No

If yes, please explain

Do you have or have you ever had any of the following *

Pacemaker

Lung disease

Rheumatic fever

Cancer

Arthritis

Chest pain, angina

Heart attack

Stroke

Shortness of breath

Mitral Valve Prolapse

Heart murmur

Tuberculosis

Steroid therapy

Diabetes

Stomach ulcers

Drug/alcohol dependency

Seizures (epilepsy)

Thyroid disease

Kidney disease

Osteoporosis medications (e.g. Fosamax, Actonel)

none of the above

Are there any conditions or diseases not listed that you have or ever had *

Yes

No

If yes, please explain

Do you smoke or chew tobacco products

Yes

No

Do you have a history of snoring, sleep apnea *

Yes

No

If so, do you use a home CPAP machine

Are you anxious during dental treatment *

Yes

No

If yes, please rate, (one is low, five is high)

Have you received treatment for alcohol or drug use *

Yes

No

Do you use narcotics or sedatives on a regular basis *

Yes

No

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

I, the undersigned, certify that all of 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 physician being contacted if necessary to obtain information that is required for my dental care.

Sedation Medical Questionnaire

PATIENT MEDICAL HISTORY

MEDICAL HISTORY QUESTIONNAIRE

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