SOUTH PACIFIC Dental Anesthesia Health History Form
Please promptly complete this form once requested. Delays in completing the form may require rescheduling your procedure. If you have any questions, please contact SPMOBILESLEEP@GMAIL.COM or 949-478-2741
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Email *
www.southpacificanesthesia.com
Patient Full Name *
Patient Date of Birth *
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Address: Street, City, State, Zip code *
Cell Phone Number *
Emergency Contact *
Provide the name and relationship of your emergency contact.
Emergency Contact Phone Number *
Dental office where the procedure will be performed *
What is the dental procedure that will be performed? *
Procedure date and time if scheduled
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Time
:
Primary Care Physician (PCP) and Phone Number *
Please list the name and phone number.  If you do not have a PCP, type "None".  
Medical Specialists *
Select the all Medical Specialists that you have.  
Required
Medical Specialists
List the names and phone numbers of any Medical Specialists selected above. 
Patient Age *
Patient Gender *
Height *
Weight *
Allergies *
Please list all allergies to medications.  If you do not have any allergies, please type "None"
Medications *
Please list all medications and supplements you are currently taking.  If you are not taking medications, please type "None".  Alternatively, you may email the list of medications to info@premiersedation.com
Do you take any of the following medications for weight loss or diabetes?:
 *
GLP-1 Receptor Agonists 
Semaglutide(Ozempic®, Wegovy®, Rybelsus®), Dulaglutide (Trulicity®), Liraglutide (Victoza®), Exenatide (Byetta®,Bydureon®),  Lixisenatide (Adlyxin®)
SGLT-2 Inhibitors
Empagliflozin (Jardiance®), Dapagliflozin (Farxiga®), Canagliflozin (Invokana®), Ertugliflozin (Steglatro®), Bexaglifloxin (Brenzavvy®) 
Anesthesia *
Yes
No
Any problems with anesthesia before? (If N/A, select "No".)
Any family history of problems with anesthesia?
Prior Surgeries *
List all prior surgeries and the approximate year or your age at the time surgery
Social
 *
Currently
Previously
Never
Alcohol use (more than 7 drinks per week)
Tobacco use
Marijuana use
Recreational drug use
Physical Ability *
Can you?
Yes
No
Lay flat on your back
Tilt your head back
Get dressed on your own
Walk briskly on flat ground for 5 minutes without stopping
Walk up a flight of stairs without stopping
Carry a bag of groceries up a flight of stairs without stopping
Walk uphill for 5 minutes without stopping
Do you exercise regularly?
Heart *
Do you have a history of or currently have?
Yes
No
Heart attack or myocardial Infarction
Coronary artery disease
Heart failure
Heart valve disease
Pulmonary Hypertension
Congenital heart disease at birth
High Blood Pressure
Chest pain or angina
Abnormal heart rhythm or arrhythmia
Heart murmur
Pacemaker or defibrillator
Any prior heart studies (stess test, echocardiogram, etc)
Other heart disease (explain below)
Lungs *
Do you have a history of or currently have?
Yes
No
Cold, cough, or respiratory illness in the last month
Asthma
COPD or emphysema
Bronchitis
Sleep apnea
Severe Snoring
Restrictive lung disease
Other lung disease (explain below)
Nervous System *
Do you have a history of or currently have?
Yes
No
Stroke
Epilepsy or history of seizures
Down Syndrome
Developmental delay or intellectual disability
Autism
Congenital or genetic syndrome (Please explain below)
Cerebral Palsy
Dementia or cognitive decline
Multiple Sclerosis
Other nervous system disease (explain below)
General medical conditions *
Do you have a history of or currently have?
Yes
No
Bleeding or clotting disorder
Diabetes
Reflux or GERD
Kidney disease or kidney failure
History of urinary retention
Enlarged prostate
Incontinence
Liver disease or hepatitis
Thyroid disease
Psychiatric illness
Neck pain
Back pain
Have you been unexpectedly hospitalized in the last 6 months?
List any other health conditions that are not listed above. 
 *
If none, type "None". Additionally, please explain any medical conditions if indicated above.
Any questions or concerns regarding anesthesia? *
If none, type "None".
Required Disclosures *
Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email: licensecheck@mbc.ca.gov, or call (800) 633-2322.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov
Required
Pregnancy Statement
 *

Anesthesia may be harmful to an unborn child (e.g. contribute to birth defects, spontaneous abortion). You are responsible to inform the anesthesiologist of confirmed pregnancy or the possibility of being pregnant. If pregnancy is a possibility, you should consider taking a pregnancy test before the procedure and providing the results with the anesthesiologist.

Pre-Anesthesia Instructions
 *
Eating and drinking:
Do not eat or drink anything for 8 HOURS prior to the procedure. However, you may have water up until 2 HOURS prior to the procedure.

FAILURE TO FOLLOW THIS INSTRUCTION MAY RESULT IN SEVERE HARM INCLUDING ASPIRATION AND POSSIBLY
DEATH.

Health and medications:
Please notify your anesthesiologist if there has been recent change in your health including any recent cold or cough symptoms prior to the procedure. Prescription medications may be taken with a small sip of water as scheduled until 60 minutes prior to the procedure unless instructed otherwise.

Discharge escort following anesthesia:
Every patient must arrange to be accompanied home from the dental office by a person they know. It is highly recommended that this person spend the rest of the day with you.

Pediatric patients:
Please bring a blanket to keep the patient warm. For small children, it is recommended to bring a change of clothes as well.
Required
Post-Anesthesia Instructions
 *
Pain:
Tylenol (Acetaminophen) and Motrin (Ibuprofen) may be taken as needed for pain as long as you do not have allergies to these medications. Tylenol may be taken immediately but please delay taking Motrin for 6 hours following anesthesia as a similar medication is given during the procedure. If a narcotic medication is prescribed by the dentist, do not take Tylenol while taking that narcotic medication. Muscle aches and a sore throat may occur after anesthesia. If these do occur, they will usually resolve within 24 hours.

Diet:
Limit oral intake to liquids for the first hour following anesthesia. If teeth were extracted, do not use a straw to drink. It is important to stay hydrated and drink plenty of fluids. Gradually progress from clear liquids to soft foods and then to a full diet as tolerated. Be careful not to bite a numb lip or tongue.

Activity:
The patient should rest quietly with a responsible adult following anesthesia. Balance, coordination, and judgment may be impaired. Please avoid activities which require these skills (driving, operating heavy machinery, making significant decisions, moderate to high physical activity, etc). Please do not leave children alone for the first 6 hours following anesthesia.
Required
Anesthesia Consent
 *
TYPES OF ANESTHESIA
General Anesthesia – use of intravenous and/or inhalation agents which will cause unconsciousness. A breathing tube is often required to protect your airway.

Regional Anesthesia – use of anesthetizing agents and/or narcotics injected around a nerve(s) so as to produce a loss of sensation and/or movement of a specific part of the body.

Monitored Anesthesia Care – commonly known as “twilight” anesthesia, this involves the use of different anesthetic agents to produce various levels of sedation and/or analgesia. The patient is usually able to maintain their own breathing without the use of an advanced airway.

During the procedure, you may need additional anesthesia, type or techniques, and/or monitoring. Signing this consent allows your anesthesiologist to provide you with such services for your own comfort, safety and well-being.

PEDIATRIC PATIENTS
The administration and monitoring of general anesthesia may vary depending on the type of procedure, the type of practitioner, the age and health of the patient, and the setting in which anesthesia is provided. Risks may vary with each specific situation. You are encouraged to explore all the options available for your child’s anesthesia for his or her dental treatment, and consult with your dentist or pediatrician as needed.

For the safety of your child, parents are not allowed to watch the anesthesia procedures or dental treatment. If a parent refuses to leave after being requested to do so, the procedure will be cancelled.

RISKS AND ALTERNATIVES
There are risks involved in any type of anesthesia. It is not possible to guarantee or give assurance of a successful result. It is important that you clearly understand and agree to the planned anesthetic, the possible risks, complications and alternatives.

Risks and complications include but are not limited to: allergic reactions, infection, nose bleeding and/or generalized bleeding, remembrance of procedures, nausea, vomiting, nerve injury, dental damage, eye injury, tissue damage, aspiration, breathing problems, urinary retention, agitation or delirium upon awaking and in extremely rare cases, major organ damage, coma, or even death.

Alternatives include proceeding without anesthesia and postponing, cancelling, or rescheduling the procedure to be performed at a surgery center or hospital.
Required
Signature (Type your name)
 *
If the patient is not able to consent this signature should be the person responsible for making medical decisions for the patient. 
Today's Date *
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A copy of your responses will be emailed to the address you provided.
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