General & Health History

Contact & Identification

Email *

Patient Full Name *

Patient Date of Birth *

Address: Street, City, State, Zip *

Cell Phone Number *

Emergency Contact (name & relationship) *

Emergency Contact Phone Number *

Procedure Details

Dental office where the procedure will be performed *

What is the dental procedure that will be performed? *

Procedure Date (if scheduled)

Procedure Time (if scheduled)

Physician & Specialists

Primary Care Physician (PCP) Name *

PCP Phone Number

Medical Specialists *

None Cardiologist Pulmonologist Neurologist Endocrinologist Other

Select all that apply, or "None". Selecting a specialist opens a spot to add their contact info.

Patient Profile

Age *

Gender *

Height *

Weight *

Allergies to medications *

Current medications and supplements *

Do you take any GLP-1 receptor agonist or SGLT-2 inhibitor for weight loss or diabetes? *

Semaglutide (Ozempic, Wegovy), Dulaglutide (Trulicity), Liraglutide (Victoza), Empagliflozin (Jardiance), Dapagliflozin (Farxiga), and similar medications.

Yes No

Anesthesia & Surgical History

Any problems with anesthesia before? * Yes No

Any family history of problems with anesthesia? * Yes No

List all prior surgeries and the approximate year or your age at the time *

Current & Prior Daily Habits

In the past 12 months, have you used any of the following on a daily basis?

Before the last 12 months, did you ever have a history of heavy use or addiction to:

Physical Ability

Can you do the following?

Condition	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
Exercise regularly

Heart

Do you have a history of or currently have:

Condition	Yes	No
Heart attack or myocardial infarction
Coronary artery disease
Heart failure
Heart valve disease
Congenital heart disease at birth
Chest pain or angina
Abnormal heart rhythm or arrhythmia
High blood pressure
Heart murmur
Pacemaker or defibrillator
Any prior heart studies (stress test, echocardiogram, etc.)
Other heart disease (explain below)

Lungs

Do you have a history of or currently have:

Condition	Yes	No
Cold, cough, or respiratory illness in the last month
Asthma
COPD or emphysema
Bronchitis
Pulmonary hypertension
Sleep apnea
Severe snoring
Restrictive lung disease
Other lung disease (explain below)

Nervous System

Do you have a history of or currently have:

Condition	Yes	No
Stroke
Epilepsy or history of seizures
Down syndrome
Developmental delay or intellectual disability
Autism
Congenital or genetic syndrome (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:

Condition	Yes	No
Bleeding or clotting disorder
History of nose bleeds
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
Unexpectedly hospitalized in the last 6 months

Other health conditions not listed above *

Any questions or concerns regarding anesthesia? *

Required Disclosures & Consent

Required Disclosures

Medical doctors are licensed and regulated by the state medical board. To verify a license or file a complaint, contact your state medical board directly.

For informational purposes, the federal Physician Payments Sunshine Act requires that payments and other transfers 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 through the CMS Open Payments database.

I have read the Required Disclosures.

Pregnancy Statement

Anesthesia may be harmful to an unborn child (for example, it may contribute to birth defects or spontaneous abortion). You are responsible for informing the anesthesiologist of a confirmed pregnancy or the possibility of pregnancy. If pregnancy is a possibility, consider taking a pregnancy test before the procedure and share the results with the anesthesiologist.

I have read and understand the Pregnancy Statement.

Pre-Anesthesia Instructions

Eating and drinking: Do not eat or drink anything for 8 hours prior to the procedure. Water only may be taken up until 2 hours prior. Failure to follow this instruction may result in severe harm, including aspiration and possibly death.

Health and medications: Notify the anesthesiologist of any recent change in health, including cold or cough symptoms. 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: Every patient must be accompanied home by a responsible adult they know, who should ideally spend the rest of the day with them.

I have read the Pre-Anesthesia Instructions and understand the procedure may be cancelled if they are not followed.

Post-Anesthesia Instructions

Pain: Acetaminophen and ibuprofen may be taken as needed if you are not allergic, though ibuprofen should wait 6 hours after anesthesia. Muscle aches and a sore throat may occur and typically resolve within 24 hours.

Diet: Limit oral intake to liquids for the first hour. Do not use a straw if teeth were extracted. Progress gradually from clear liquids to soft foods.

Activity: Rest with a responsible adult. Avoid driving, operating machinery, making significant decisions, or moderate-to-high physical activity while judgment and coordination are impaired.

I have read the Post-Anesthesia Instructions.

Anesthesia Consent

Types of anesthesia: General anesthesia (unconsciousness, often with a breathing tube); regional anesthesia (loss of sensation in a specific area); and monitored anesthesia care, or "twilight" sedation, using agents to produce varying levels of sedation while the patient typically maintains their own breathing.

Pediatric patients: Anesthesia and monitoring may vary with the procedure, practitioner, and the patient's age and health. For the safety of the child, parents are not permitted to observe the anesthesia or dental treatment; the procedure will be cancelled if a parent refuses to leave after being asked.

Risks and alternatives: Risks include, but are not limited to, allergic reaction, infection, bleeding, nerve injury, dental or tissue damage, aspiration, breathing problems, urinary retention, agitation on waking, and in extremely rare cases major organ damage, coma, or death. Alternatives include proceeding without anesthesia, or postponing the procedure to a surgery center or hospital setting.

I have read the Anesthesia Consent, understand the risks, complications, and alternatives, and I agree and consent to proceed with anesthesia.

Signature (type your full name) *

Today's Date *

If the patient cannot consent, this signature should be the person responsible for making medical decisions for the patient. A copy of your responses is kept on file with Dharini Patel MD INC..

Condition	Yes	No
Alcohol (more than 2 drinks per day)
Tobacco or nicotine
Marijuana
Other illicit drugs (including prescription drugs used recreationally)

Condition	Yes	No
Alcohol
Tobacco or nicotine
Marijuana
Other illicit drugs (including prescription drugs used recreationally)

Health history received

Contact & Identification

Procedure Details

Physician & Specialists

Patient Profile

Anesthesia & Surgical History

Current & Prior Daily Habits

Physical Ability

Heart

Lungs

Nervous System

General Medical Conditions

Required Disclosures & Consent

Required Disclosures

Pregnancy Statement

Pre-Anesthesia Instructions

Post-Anesthesia Instructions

Anesthesia Consent