Medical History Form - Pediatric Dental Anesthesia Associates

Request for Medical History

Has this patient or any other family members been a patient of PDAA previously?^*YesNo

Patient First Name^*

Patient Last Name^*

Gender^*MaleFemale

Age^*

Date of Birth^*

Parent Name^*

Child's Weight^*

Home Phone

Work Phone

Cell Phone^*

Email^*

Dentist's Name^*

Dentist's Location (Search by Name or Location)

Does your child take any medications?^*YesNo

Allergies^*YesNo

Recent cold, cough or reactive airway^*YesNo

Snoring, asthma or breathing problems^*YesNo

If your child is under the care of a pulmonologist, please provide their name and phone number if you have it available

Heart trouble, murmur, or heart surgery^*YesNo

If your child is under the care of a cardiologist, please provide their name and phone number if you have it available

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

How many minutes is your drive from home to the dental office?^*