• Bluejack Preoperative Sedation Screening — Version 2.0

    Complete this form to assist in anesthesia clearance for dental implant procedures. Please answer all questions accurately to ensure your safety during treatment.

  • Patient Information

    Please provide your personal and contact details.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Do you have any allergies or serious reactions to medications or latex?*

  • Cardiovascular History

    Please answer the following about your heart and blood vessels.
  • Do you have high blood pressure (hypertension)?*
  • Have you ever had a heart attack (myocardial infarction)?*
  • Have you ever been diagnosed with heart failure?*
  • Is your heart failure currently well controlled?*
  • Do you currently experience shortness of breath at rest or when lying flat?*
  • Have you ever been diagnosed with an abnormal heart rhythm(arrhythmia) such as atrial fibrillation, SVT, ventricular arrhythmia, heart block?*
  • Do you have a pacemaker or implanted defibrillator (ICD)?*
  • Do you currently have chest pain, chest pressure, or angina?*
  • Have you had a coronary stent placed?*
  • Have you been told you have a heart valve problem (such as aortic stenosis, mitral regurgitation, or valve replacement)?*

  • Pulmonary History

    Please answer the following about your lungs and breathing.
  • Have you been diagnosed with asthma?*
  • Have you ever been diagnosed with COPD or chronic lung disease (emphysema, chronic bronchitis)?*
  • Have you been diagnosed with obstructive sleep apnea?*

  • Please bring your CPAP machine the day of surgery 

  • Do you currently smoke or use tobacco?*
  • How much do you smoke?*
  • Do you use home oxygen?*
  • Do you vape?*
  • Have you ever been diagnosed with pulmonary hypertension?
  • Recent Respiratory Infection, COVID, or Pneumonia (within last 4 weeks)?*

  • Airway Risk

    Please answer the following regarding your airway and breathing risk.
  • Have you ever been told you have a difficult airway or required special equipment for intubation?*
  • Have you ever had any of the following during anesthesia? (select all that apply)*
  • Do you have difficulty opening your mouth wide?*
  • Do you have difficulty fully extending or moving your neck?*
  • What is the reason? (Select all that apply)*
  • How limited is your neck movement?*
  • Do you have loose teeth, dentures, or dental appliances?*

  • Neurologic

    Please answer the following about your brain and nerves.
  • Have you fainted or lost consciousness (syncope) within the last 12 months?*
  • Have you ever had a stroke or TIA?*
  • After your stroke or TIA, do you currently have any lasting problems such as weakness, difficulty speaking, or memory/thinking problems?*
  • Do you have a history of seizures?*
  • Are you currently taking medication for seizures?*

  • Endocrine

    Please answer the following about your hormones and glands.
  • Diabetes*
  • Do you use insulin?
  • Have you been diagnosed with thyroid disease?*
  • Have you ever been diagnosed with adrenal gland disease?*

  • Kidney and Liver

    Please answer the following about your kidney and liver health.
  • Do you have kidney disease?*
  • Do you have liver disease?*
  • Have you ever been diagnosed with cancer?*
  • Are you currently receiving chemotherapy, radiation, or immunotherapy?*
  • Has your cancer caused significant weakness, weight loss, breathing problems, or other major health effects?*

  • Gastrointestinal

    Please answer the following about your stomach and digestion.
  • Do you have a history of GERD (acid reflux)?*

  • Medications

    Please list all current medications and supplements.
  • Do you currently take any medications or supplements?*
  • Medication Categories*
  • Do you take any blood thinners?*
  • Anticoagulant / Relevant Medication List*
  • Reason for Blood Thinner
  • Do you currently use any of the following substances? (Select all that apply)*
  • Have you used marijuana, cocaine, methamphetamines, or other recreational drugs in the past 72 hours?

  • Anesthesia History

    Please answer the following about your past anesthesia experiences.
  • Have you had any previous complications with anesthesia or sedation?*
  • Malignant hyperthermia is a rare but serious reaction to anesthesia that may have occurred in you or a blood relative during surgery (high fever, muscle rigidity, or anesthesia complications). Have you or any blood relative ever been diagnosed with or suspected to have malignant hyperthermia?*

  • Neuromuscular Disorders

    Please tell us if you have any conditions affecting your muscles or nerves.
  • Have you been diagnosed with a neuromuscular disorder?*
  • Which condition(s) have you been diagnosed with?
  • Do you have difficulty swallowing, breathing, or holding your head up due to this condition?

  • Functional Capacity

    Please answer the following about your daily activity.
  • Can you climb two flights of stairs without stopping due to chest pain or shortness of breath?*

  • Specialist Care

    Provide information about any specialists involved in your care.
  • Are you currently under the care of any of the following specialists?*

  • Recent Health

    Tell us about any recent illnesses or hospitalizations.
  • Recent Hospitalization or Emergency Room Visit (within last 6 months)?*
  • Are you currently pregnant or possibly pregnant?*

  • Consent

    Please read and sign below to confirm your understanding and agreement.
  • Date of signature*
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  • Clinician summary: This form combines the patient's medical history, medications, and anesthesia-related risk factors to support sedation planning and assist provider risk assessment. Final treatment and sedation decisions remain at provider discretion.

  • Bluejack provides screening support and advisory recommendations only. Final sedation, procedural, and treatment decisions remain solely at the discretion of the treating provider.

  • Internal Results

    Internal trigger fields live here and feed the explanation text below. They are not shown to patients.

  • Risk Factors Identified

    Patient presents with one or more anesthesia-related risk factors. See above for details.
  • Should be Empty: