Intravenous Sedation Questionnaire

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

Please list any other allergies:

Females:

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

Your Signature