• Health History
  • Name
  • Date
  • Email
  • Date if last health care exam:
  • What was this exam for?
  • Have you been hospitalized or had surgery? (Please check)
  • Yes No
  • If yes, reason:
  • Are you currently receiving care?
  • Yes No
  • If yes, nature of care:
  • Please list all the names and phone numbers of the physicians who are currently providing you care:
  • 1.
  • 2.
  • 3.
  • 4.
  • For the following questions check yes or no. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health.
  • Yes No
    Blood Disorders?
    Arthritis, Rheumatism or other inflammatory disease?
    Asthma, COPD or other Lung Diseases
    Abnormal Bleeding from a cut?
    Cancer or Tumor?
    Emphysema or other Respiratory/Lung Illnesses
    Fainting or Dizzy Spells
    Previous Bacterial Endocarditis
    Heart Valve (artificial) or Heart Transplant
    Congenital Heart Disease
    Heart Disease, Heart Attack, Heart Surgery, Angina
    Heart Stent? When placed?
  • Yes No
    Hepatitis, Any Form
    Joint Replacement? When placed?
    Kidney Disease
    Liver Disease (including Jaundice)
    Sore/Enlarged Lymph Nodes
    Psychiatric Therapy
    Previous Biopsies
    Radiation or Chemotherapy Treatment
    Renal Dialysis
    Slow-Healing Mouth Sores
    Unintentional Weight Loss/Gain
    H.I.V. Infection/AIDS or ARC
    Venereal Disease
    Other Conditions
    Recurrent Illness
  • Are you taking any of these medications?
  • Yes No
    Pre-medication before dental treatment?
    St. John's Wort or Kava-Kava?
    Dilantin® or Tegretol®
  • Yes No
    Biaxin® (clarithromycin)
    Cardizem® (diltiazem) or Calan, Isoptin® (Veraoamil)?
    Diflucan (flucoazole) or Sporonox (itraconazole)
  • Have you been treated with Bisphosphonate drugs (Fosamax®, Aredia®, Zometa®, Actonel®, Boniva®, RECLAST) or PROLIA? If so, when did the treatment begin? When did the treatment end?
    Yes No
  • Do you consume grapefruit juice, grapefruits or grapefruit extract?
  • Yes No
  • Please list any medications you are currently taking and dosages:
  • 1.
  • 3.
  • 5.
  • 7.
  • 2.
  • 4.
  • 6.
  • 8.
  • Please list any dietary or herbal supplements you are taking, and for what purpose:
  • 1.
  • 3.
  • 5.
  • 7.
  • 2.
  • 4.
  • 6.
  • 8.
  • Do you use recreational drugs?
  • If so, which ones?

  • Sleep:
  • Yes No
    1. Do You Suspect or have you been told that you snore?
    2. Do You Suspect or have been diagnosed with sleep apnea?
    3. Are you being treated for sleep apnea with a CPAP, BiPAP, or other device?
  • Women:
  • Yes No
    Are you pregnant?
    If no, are you planning a pregnancy in the near future?
    Are you a nursing mother?
    Are you taking birth control pills?
  • Abnormal Blood Pressure? (Please check)
  • Yes No
  • Have you ever received a diagnosis of "high blood pressure" or "low blood pressure"?
  • What is your normal blood pressure?
  • S /D Today: S /D
  • Are you allergic or have you had a reaction to:
  • Yes No
    a. Local anesthetics or epinephrine
    b. Penicillin or other antibiotics
    c. Aspirin, Ibuprofen or Tylenol®
    d. Codeine, Valium®, Hydrocodone, Oxycodone or other sedatives
    e. Latex or Metals
  • f. Other (please specify)
  • Tobacco, Alcohol, Drugs
  • Do you use tobacco? If yes, check type:
  • Smoke Chew
  • How much per day?
  • For how long?
  • Do you want to quit using tobacco?
  • Yes No
  • Do you consume alcohol? If yes, approximately how many alcoholic beverages per week?
  • Yes No
  • Do you use any mood altering drugs other than those previously listed?
  • Yes No
  • Weight and Diet considerations
  • Weight Height Meals Per Day Dietary Restrictions Food Allergies
    • Suger in your diet (check one):
    • Slight Moderate High

  • Comments on patient interview concerning medical history:
  • ____________________________________________________________________________
  • Significant findings from questionnaire or oral interview:
  • ____________________________________________________________________________
  • Dental management considerations:
  • ____________________________________________________________________________
  • I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of change in my health and medication.
  • Patient (Print Name)
  • Signature
  • Date
  • Doctor (Print Name)
  • _______________________
  • Doctor Signature
  • _______________________
  • Date
  • _______________________

  • The purpose of this document is to provide an opportunity for patients to understand and give permission for oral conscious (minimal or moderate oral) sedation ("OCS") when provided along with dental treatment. Each item should be initialed after the patient has the opportunity for discussion and questions.
  • 1. I understand that the purpose of OCS is to more comfortably receive necessary care. OCS is not required to provide the necessary dental care. I understand that OCS has limitaions and risks and absolute success cannot be guaranteed. (See #4 options.)
  • 2. I understand that OCS is a drug-induced state of reduced awareness and decreased ability to respond. OCS is not sleep. I will be able to respond during the procedure. My ability to respond normally returns when the effects of the sedative wear off.
  • 3. I understand that my OCS will be achieved by the following route:
    • Oral Administration: I will take a sedative(s) approximately __________ minutes before (and possibly again during) my appointment. The sedation will last approximately __________ to __________ hours.
  • 4. I understand that the alternatives to OCS are:
    • a. No sedation: The necessary procedure is performed under local anesthetic with the patient fully aware.
    • b. Nitrous oxide sedation: Commonly called laughing gas, nitrous oxide provides relaxation but the patient is still generally aware of surrounding activities. Its effects can be reversed in five minutes with oxygen.
    • c. Anxiolysis (or minimal) sedation: A pharmacologically induced state of consciousness where an individual is awake but has decreased anxiety to facilitate coping skills, retaining interactive ability.
    • d. Oral conscious (minimal or moderate oral) sedation: Sedation via pill form that will put me in minimally to moderately depressed level of consciousness.
    • e. Intravenous (I.V.) conscious () sedation: The doctor could inject the sedative in a tube connected to a vein in my arm to put me in a minimally to moderately depressed level of consciousness.
    • f. General anesthesia: Also called deep sedation, a patient under general anesthetic has no awareness and must have their breathing temporarily supported. General anesthesia is more appropriate for longer procedures lasting 3 or more hours.
  • 5. I understand that there are risks or limitations to all procedures. For sedation these include:
    • (oral sedation) Inadequate sedation with initial dosage may require the patient to undergo the procedure without full sedation or delay the procedure for another time. Likewise, in compliance with state regulations, an additional dose or doses may be required to complete the procedure.
    • Atypical reaction to sedative drugs that may require emergency medical attention and/or hospitalization such as altered mental states, physical reactions, allergic reactions, and other sicknesses.
    • Inability to discuss treatment options with the doctor should circumstance requires a change in treatment plan.
  • 6. If, during the procedure, a change in treatment is required, including abandoning the original treatment plan if medically/professionally necessary, I authorize the doctor and the operative team to make whatever change they deem in their professional judgment is necessary. I understand that I have the right to designate the individual who will make such a decision.
  • 7. I have had the opportunity to discuss OCS and have my questions answered by qualified personnel including the doctor. I also understand that I must follow all the recommended treatments and instructions of my doctor.
  • 8. I understand that I must notify the doctor if I am pregnant, or if I am lactating. I must notify the doctor if I have sensitivity to any medication, of my present mental and physical condition, if I have recently consumed alcohol, and if I am presently on psychiatric mood altering drugs or other medications.
  • 9. I will not be able to drive or operate machinery while taking oral sedatives for 24 hours after my procedure. I understand I will need to have arrangements for someone to drive me to and from my dental appointment while taking oral sedatives.
  • I hereby consent to OCS in conjuction with my dental care.
  • Patient / Guardian
  • Signature
  • Date

  • Prior to Sedation Visit
  • Date
  • Patient
  • Gender
  • Male Female
  • Medical Status ASA:
  • I II III
  • Age:
  • Height
  • Weight
  • lbs.
  • kg.(lb/2.2)
  • BMI:
  • Allergies (drug & food):
  • Pre-Medication for
  • AB
  • Dose:
  • Time:
  • Diet habits: Eats/snacks every
  • hours.
  • Usual bathroom routine:
  • Dietary notes & amount of sugar in diet:
  • Can we give your post op instructions to your driver?
  • (Patient initials)
  • Alcohol Consumed in a week
  • Recreational drugs (& how ofter):
  • Normal daily medications (& dosage):
  • Did you take them?
  • Yes No
  • (patient initials)
  • LexiComp compared and in chart.
  • Smoker (how much)
  • Gagger(check)
  • __1   __2   __3   __4
  • Baseline Pulse
  • ______________
  • Sa O2:
  • ______________ %
  • BP:
  • ______________
  • Respiratory Rate (pre-op)
  • ____________________ (breaths/min)
  • Mallampatti Classification
  • Premed Rx
  • ______________
  • (daiz, triaz, loraz)
  • Specific Instructions:
  • ______________
  • List current dental needs:
  • On a scale 1-10 how anxious are you about the dental visit?
  • Do you have a history with sedation?
  • What are your expectations of the sedation visit?
  • Day of Treament
  • Last food or water other than medications: _________________ Date _________________ Time
Medication Time Route Dosage
Medication Time Route Dosage
  • TOP Dose = ______________________________ Pt. Wgt/QF (QF triazolam = 100 QF Lorazepam = 25)
  • 2% Mepivacaine 1:20,000 Neo:
  • ______________________________
  • 3% Mepivacaine
  • ______________________________
  • 2% Lidocaine with 1:100,000 epi:
  • ______________________________
  • 3% Polocaine
  • ______________________________
  • 4% Septocaine w/1:100K epi:
  • ______________________________
  • 4% Citanest Plain:
  • ______________________________
  • 0.5% Marcaine with 1:200,000 epi:
  • ______________________________
  • Vital signs: photocopy of Criticare monitor printout is on back of this sheet.
  • General nature of dental procedure:
  • ______________________________
  • Bathroom visits:
  • ______________________________
  • Food:
  • ______________________________
  • Companion's name and phone number:
  • ______________________________
  • Completion of Sedation
  • ____ Post op respiratory rate: ______________________ (breaths/min)
  • ____ Monitor print out copied and stapled to from
  • ____ All of patient's property returned to caregiver (glasses, watch, pill bottle, etc.)
  • ____ Patient tolerated treatment well and was ambulatory and oriented X 3 when they left.
  • ____ ____ mg Advil/ ____ mg Tylenol given ____________
  • ____ Gatorade ____ Juice ____ Post op instructions
  • ____ Moderate ____ light ____ comfortable ____ adjust next visit more ____ adjust next visit less
  • Doctor's signature
  • ______________________________
  • Assistant's name
  • ______________________________

  • Sedation Instruction Sheet
  • Non-smokers will receive three (3) prescriptions - Valium, Halcion, and pain medication.
  • Smokers will receive four (4) prescriptions - Valium, Halcion, Hydroxyzine, and pain medication. Nicotine levels in your blood will affect your sedation experience----Hydroxyzine 10mg is prescribed to those who smoke.
  • The Evening Before Your Appointment:
    • Take 1 Valium at bedtime. NO FOOD or DRINK after taking this medication.
    • The medication works best on an empty stomach.
  • The Morning of Your Appointment:
    • Take 1 Halcion 0.25mg exactly 1 hour before your appointment time. Bring all remaining medication with you to the appointment to be administered by the doctor. just enough water to swallow the medications. STILL NO FOOD OR DRINK
  • No alcohol or narcotic drugs unless authorized by the doctor.
    • We cannot safely sedate you if you have consumed alcohol, narcotics of any type (including Vicodin/Hydrocodone) or any street or recreational drugs.
  • Leave all valuables, purse, wallet, and watches at home or with your companion.
  • Wear comfortable clothing.
  • Wear comfortable socks and shoes.
  • Bring along your favorite blanket and/or listening device with earbuds.
  • No nail polish please.
  • It is absolutely necessary that you have your companion/guardian drive you to and from your appointment. We will not be able to proceed with your appointment if you drive yourself, and this will result in a forfeiting of your prepaid fee.
  • Your companion will also need instructions, so please have him/her speak with the dental team before dropping you off and picking you up. Should your companion wish to remain here during the sedation visit, we have a comfortable waiting area for their use.

  • Consent Form
  • Patient Number
  • Patient's Name
  • Date of Birth
  • I hereby authorize and whomever he/she designate as his/her assistants, to perform upon me the following operation and/or procedures:
  • I request and authorize him/her to do whatever he/she deems advisable if any unforeseen condition arises in the course of these designated operations and/or procedures calling, in their judgment, for procedures in addition to or different from those now contemplated.
  • I consent to the above treatment after having been advised of the risks, advantages and disadvantages of the treatments and the consequences if this treatment were withheld.
  • I consent to the above treatment plan after having been advised of the alternate plans of treatment available and the known material risks, advantages and disadvantages of the alternative treatment.
  • I further consent to the administration of local or general anesthesia, antibiotics, analgesics, nitrous oxide or any other drugs that may be deemed necessary in my case, and understand that there is a slight element of risk inherent in the administration of any drug or anesthesia. This risk includes adverse drug response (e.g., allergic reactions), cardiac arrest, and aspiration, and thrombophlebitis (e.g. irritation and swelling of a vein), pain, discoloration and injury to blood vessels and nerves which may be caused by injections of any medications or drugs.
  • I am informed and fully understand that inherent in any type of surgery are certain unavoidable complications. In oral surgery, the most common of these complications include post-operative bleeding, swelling or bruising, discomfort, stiff jaws, loss or loosening of dental restorations. Less common complications can include infection, loss or injury to adjacent teeth and soft tissues, nerve disturbances (e.g., numbness in mouth and lip tissues), jaw fractures, sinus exposure and swallowing or aspiration of teeth and restorations, and small root fragments remaining in the jaw which might require extensive surgery for removal.
  • I realize that in spite of the possible complications and risks, my contemplated surgery/treatment is necessary and desired by me. I am aware that the practice of dentistry and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results of the operation or procedure.
  • I have provided as accurate and complete a medical and personal history as possible including those antibiotics, drugs, medications and food to which I am allergic. I will follow any and all instructions as explained and directed to me and permit prescribed diagnostic procedures.
  • I have had the opportunity to ask questions and receive answers to and responsive explanations for, all questions about my medical condition, contemplated and alternative treatment and procedures, and the risk and potential complications of the contemplated and alternative treatments and procedures, prior to signing this form.
  • Patient or Guardian's Signature
  • Date
  • Dentist's Signature
  • ___________________________
  • Date
  • ___________________________
  • Witness's Signature
  • ___________________________
  • Date
  • ___________________________

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