Contact us via
info@wadentalsedations.com.au
Your Team
For Patients
Dental Professionals
Clinical Booking (Office Use Only)
Availability
Medical History
Home
/
Medical History
All questions are highly important and will be kept strictly confidential
Please enable JavaScript in your browser to complete this form.
Name
*
Gender
*
Male
Female
Date of Birth
*
Address
*
Suburb
Postcode
*
Phone (Mob)
*
Phone (Home)
*
Phone (Work)
*
Email
*
Your Dental Practice
*
Occupation
*
Private Health Fund
*
Please state the name of your health fund, alternatively put NA if not applicable.
Name and Location of your Medical Doctor GP or Specialist
*
Please Tick Y/N if you have, or have ever had, any of the following:
Heart issues/Angina/Infarction
*
Yes
No
Shortness of breath/Chest issues
*
Yes
No
Reflux or indigestion
*
Yes
No
Murmur/prosthetic heart valve
*
Yes
No
Emphysema/COPD/Lung conditions
*
Yes
No
Glaucoma
*
Yes
No
Rheumatic fever/infective Endocarditis
*
Yes
No
Asthma/bronchitis
*
Yes
No
Prosthetic joints/replacement
*
Yes
No
Congenital heart disease
*
Yes
No
Obstructive Sleep apnea
*
Yes
No
Snoring
*
Yes
No
Bone disease and Osteoporosis
*
Yes
No
High or low blood pressure
*
Yes
No
Liver disease
*
Yes
No
Epilepsy, seizures or faints
*
Yes
No
Bleeding Problems/blood disorders i.e Anemia
*
Yes
No
Mental or psychiatric conditions i.e. depression, anxiety
*
Yes
No
Kidney Disease
*
Yes
No
Stroke/TIA/DVT
*
Yes
No
Diabetes
*
Yes
No
Diabetes Type
*
Type I
Type II
Taking Insulin
*
Yes
No
Other Conditions
*
Yes
No
Cancer/chemotherapy/radiotherapy
*
Yes
No
Please list Other Conditions
*
Please list cancer/chemotherapy/radiotherapy
*
Pregnant
*
Yes
No
Due Date
*
Breastfeeding
*
Yes
No
Height (cms)
*
Weight (Kgs)
*
Please List ALL MEDICATIONS you are taking (include non-prescribed, herbal and over the counter meds)
*
Have you had any previous operations/anesthesia if yes, why and how long ago?
*
Have you or a family member ever had any complications with operations or anesthetics?
*
Have you had neck, back or spinal damage?
*
Yes
No
Do you have any Limitation of movement?
*
Yes
No
Do you have any ALLERGIES? (Including Drugs, Food, Substances)
*
Yes
No
What is the reaction?
*
General Health and Habits
How often do you exercise each week?
*
How many flights of stairs can you climb before getting short of breath?
*
Do you drink alcohol?
*
Yes
No
How many standard drinks per day?
*
How many standard drinks per week?
*
Do you smoke or smoked tobacco?
*
Yes
No
How many cigarettes per day?
*
Number of years
*
Year quit
Do you, or have you used any recreational drugs (Ie. Marajuana/IV Drugs)?
*
Yes
No
Specify type
*
Last used
*
Do you care for others, Ie Children, elderly, disable?
*
Yes
No
Do you live alone?
*
Yes
No
Do you have frequent falls?
*
Yes
No
Do you have vision or hearing loss?
*
Yes
No
Reason for I.V Sedation for your dental procedure
Reasons
High anxiety
Needle Phobia
Severe Gag reflex
Pain
Bad experience
Complex procedure/surgery
Other
Please specify
*
Comment
Submit
