Pediatric Dental Anesthesia Associates

Medical History


Patient’s Name:

Gender:

Age:

 

Date of Birth:

  

Parent’s Name:

Child’s height (if known):

  

Child's weight:

  lbs

Home #:

Work #:

Cell #:

Dentist:

    
Does your child take any medications?

 
Does anyone smoke in your child’s home?

Allergies

 
Recent cold or a cough

 
Snoring, asthma, reactive airway or breathing problems

 
Heart trouble, murmur, or heart surgery

 
Surgery or hospitalizations

 
Problems or complications with anesthesia

 
Epilepsy, seizures or fainting

 
Cerebral palsy, developmental delay, autism or ADHD

 
Any other medical conditions?

 

 

I have received the IV Sedation Information papers.
 

 

 

Today's Date

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Document name: Medical History
lock iconUnique Document ID: 274c5dbc66ca0047a9587bd2c92fcc61e4a95b5a
Timestamp Audit
March 5, 2021 9:33 am EDTMedical History Uploaded by Pediatric Dental Anesthesia Associates - billing@pediatricsedation.com IP 47.201.198.107
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