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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

We are currently still under restrictions, but can see patients for all necessary treatment WITH THE EXCEPTION OF regular maintenance (i.e. cleaning). Contact us for more information
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