Medical History

    MaleFemale

    Does your child take any medications?

    YesNo

    Does anyone smoke in your child’s home?

    YesNo

     
    Allergies

    YesNo

    Recent cold, cough or reactive airway

    YesNo

    Snoring, asthma or breathing problems

    YesNo

    Heart trouble, murmur, or heart surgery

    YesNo

    Surgery or hospitalizations

    YesNo

    Problems or complications with anesthesia

    YesNo

    Cerebral palsy, Epilepsy, Seizures or Fainting

    YesNo

    Developmental delay, Autism or ADHD

    YesNo

    Any other medical conditions?

    YesNo

    I have received the IV Sedation Information papers. YesNo  

    If you have any questions, please contact our billing office:

    Email: billing@pediatricsedation.com
    P.O. Box 2080
    Palm Harbor, FL 34682-2080
    Phone: 813-545-9924
    Fax: 866-773-3520

    Pediatric Anesthesia for Pediatric Dentistry