Pediatric Sedation

Patient 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, 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?


I have received the IV Sedation Information papers.




Today's Date October 28, 2021

Parent Name:

Leave this empty:

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Signature Certificate
Document name: Patient Medical History
lock iconUnique Document ID: 8d3f93dda3bc51ad5877b8593af03a7b96605585
Timestamp Audit
July 22, 2021 8:56 pm EDTPatient Medical History Uploaded by Pediatric Dental Anesthesia Associates - IP