Pediatric Sedation

Medical History

Patient’s Name:




Date of Birth:


Parent’s Name:

Child’s height (if known):


Child's weight:


Home #:

Work #:

Cell #:


Does your child take any medications?


Does anyone smoke in your child’s home?



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.



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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 - IP