IV Sedation Medical History

Ahead of a dental procedure under sedation, patients report their medical background, medications, allergies, habits and anxiety level. The clinic can then weigh risks and plan safe care.

Use this template

In the Claude connectors directory

Date

Name

Phone number

Address

Date of birth

Gender

Height

Weight

Email address

Occupation

More details on past or current medical conditions

Do you take any regular medication?

Yes No

List medications and doses (include vitamins and herbal remedies)

Do you have any allergies?

Yes No

If yes, please list them

Are you pregnant or breastfeeding?

Yes No Not applicable

Do you smoke? (cigarettes, vaping, marijuana, etc.)

Yes No

If yes, how many per day?

Do you drink alcohol?

Yes No

If yes, how much per week?

Do you feel anxious or phobic about dental treatment?

Yes No

If yes, how much?

Mild Moderate Severe Extreme

Is there anything else about your health we should know?

Yes No

If yes, please explain

Signature

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