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We Always Welcome New Patients!

FIND YOUR LOCATION | SARNIA-LONDON

About Us
Services
Locations
- London Ontario Office
- Sarnia Ontario Office

For The Dreamer
For The Parents
Forms

Pre-Anesthesia Questionnaire

For parent/Guardian or Patient

Pre-Anesthesia Questionnaire Submissions

Full Name:

Phone:

Date of Birth

Weight

Height

Has your child ever been in a hospital?

Yes

No

If so, when and why?

Was your child born prematurely?

Yes

No

Premature Weight

Has your child ever had general anesthesia or surgery?

Yes

No

If so, when and why and please detail any problems or complications.

Has anyone in your family or relatives had a problem during or after an anesthetic?

Yes

No

If yes, please explain any test done.

Has anyone in your family test positive for Malignant Hyperthermia?

Yes

No

If yes, who and what tests where performed?

Does your child have a drug allergy?

Yes

No

What type pf drug?

Does your child have other allergies?

Yes

No

What are the symptoms?

Skin Rash

Yes

No

Hives

Yes

No

Wheezing or trouble breathing

Yes

No

If yes, what was done to treat the problem?

Has your child had a head cold or cough within the past two weeks?

Yes

No

Is the cough producing mucous?

Yes

No

Does your child wear a dental plate/bridge/retainer/braces?

Yes

No

Does your child have any damaged or loose teeth?

Yes

No

Does your child take ANY medications currently?

Yes

No

What are these medications? Please list name and dose.

Does your child use or take ANY non-prescription remedies?

Yes

No

Please list these including name and dose.

Has your child had a cortisone (steroid) type drug in the past year?

Yes

No

Please list the reason and how long it was taken.

Is there anyone in the family with a bleeding problem?

Yes

No

Has your child had an excessive amount of bleeding following surgery such as tooth extraction?

Yes

No

Does your child bruise easily on areas other than the legs?

Yes

No

Does your child have any difficulty with head/neck/jaw movement?

Yes

No

Does your child have problems with muscles/joints/nervous system?

Yes

No

Has your child been exposed to any infectious diseases in the past month?

Yes

No

Does your child have or ever had any of the following? Please check all that apply.

Anemia

Seizures

Croup

Glaucoma

Arthritis

Epilepsy

Cystic Fibrosis

New Option

Hepatitis

Asthma

Convulsions

Diabetes

Jaundice

High Blood Pressure

Kidney Disease

Malignant Hyperthermia

GE Reflux

Developmental Delay

Heart Disease

Liver Disease

Lung Disease

Tuberculosis

Does your child smoke?

Yes

No

Does anyone in the home smoke?

Yes

No

If your child is of child bearing age, is she pregnant?

Yes

No

Does she take birth control pills/shots/medicine?

Yes

No

Are there any problems with your child's health not covered?

Yes

No

Additional comments.

Parent or Guardian Name

Thank you for contacting us.
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Dentistry While You Dream is dedicated to the health, safety and comfort of all of our Dreamers.

Our team is highly qualified and trained to help you obtain a healthy mouth and beautiful smile.

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Popular Services

Childrens Dentistry
Sedation Dentistry and Anaesthesia
White Crowns
Wisdom Teeth Removal
Frenectomy
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