Intravenous Sedation Questionnaire

Contact Details

Do you have any concerns about the procedure?

Please tick all that apply
Smoking
Number/day:
Alcohol
Standard drinks/week:
Recreational drugs
Asthma or persistent cough
Stopping breathing at night/sleep apnoea
Shortness of breath
High blood pressure
Chest pain/angina/heart attack
Pacemaker
Rheumatic fever
Heart murmur/valve problem
Palpitations
Blood/clotting disorders
Blood clots in legs/lungs
Diabetes
Liver problems
Kidney problems
Gastric reflux/hiatus hernia
Epilepsy/fits/nerve problems
Strokes/mini-strokes
Organ transplant
Back injury
Arthritis
Muscle problems
Cancer
Thyroid
Viral diseases (e.g. Hepatitis/HIV)
Anxiety/depression/psychological problems
Neck or jaw injury/limitation
Any capped/crowned/loose teeth
Unable to lie flat on a small pillow

Any problems with anaesthetics?
Any relatives with anaesthetic problems?
Any drug/food/tape/other allergies?

Please list any other allergies:

Females:

Could you be pregnant?
Are you breastfeeding?
Please list any medical problems
Please list past operations
Please list any medications

Declaration - I have answered the questions listed above as truthfully and accurately as possible.

Your Signature