Pediatric Sedation

Signed Patient Medical History


Signed Patient Medical History


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


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, cough or reactive airway

Snoring, asthma or breathing problems

Heart trouble, murmur, or heart surgery

Surgery or hospitalizations

Problems or complications with anesthesia

Cerebral palsy, Epilepsy, Seizures or Fainting

Developmental delay, Autism or ADHD

Any other medical conditions?


Today's Date December 5, 2022

Parent Name:

Leave this empty:

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Signature Certificate
Document name: Signed Patient Medical History
lock iconUnique Document ID: d580b1740d2c31f5845998f986bfc12ac89e7ae4
Timestamp Audit
July 22, 2021 8:56 pm ESTSigned Patient Medical History Uploaded by Pediatric Dental Anesthesia Associates - IP