Home
About Us
Services
Pediatric Dentistry
Sedation Dentistry and Anaesthesia
White Crowns
Wisdom Teeth Removal
Frenectomy
Special Care Dentistry
For The Dreamer
For The Parents
Locations
Sarnia Ontario Office
London Ontario Office
Contact
Forms
Dentist Referral Form
Adults: Medical History Form
Pre-Anesthesia Questionnaire
Pre Anesthesia Instructions
Post Anesthesia Instructions
Get in touch
(519) 474-2400
info@dwyd.ca
We Always
Welcome New Patients!
Call Us Today!
We Always Welcome New Patients!
F
IND YOUR LOCATION | SARNIA-LONDON
About Us
Services
Pediatric Dentistry
Sedation Dentistry and Anaesthesia
White Crowns
Wisdom Teeth Removal
Frenectomy
Special Care Dentistry
Locations
London Ontario Office
Sarnia Ontario Office
For The Dreamer
For The Parents
Forms
Adults: Medical History Form
Pre-Anesthesia Questionnaire
Post Anesthesia Instructions
Dentist Referral Form
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.
We will get back to you as soon as possible.
Oops, there was an error sending your message.
Please try again later.
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.
Quick Links
Home
About Us
Services
Contact
Forms
Dentist Referral Form
Adults: Medical History Form
Pre-Anesthesia Questionnaire
Popular Services
Pediatric Dentistry
Sedation Dentistry and Anaesthesia
White Crowns
Wisdom Teeth Removal
Frenectomy
Special Care Dentistry
Locations
Sarnia Ontario Office
London Ontario Office
Find Your Location
Home
About Us
Services
Locations
Share by:
