Pediatric Sedation

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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Signature Certificate
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