Dental Sedation Medical History
Personal Information
Full Name
Date of Birth
Age
Address
Phone Number
Email
Emergency Contact Name
Emergency Contact Phone
Physician & Insurance
Physician Name
Physician Phone
Insurance Carrier
Medical History
Are you currently under medical care?
Yes
No
If yes, please specify:
Have you had any of the following? (Check all that apply)
Asthma
Diabetes
Heart Disease
High Blood Pressure
Seizures
Bleeding Disorder
Other
If other, please specify:
Medications & Allergies
List all current medications:
List all allergies (drug/food/etc):
Dental History & Sedation
Have you had sedation or anesthesia before?
Yes
No
If yes, any complications?
Level of dental anxiety (1 = none, 10 = severe):
For Female Patients
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Additional Information
Other relevant health information: