Pediatric Sedation

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?


I have received the IV Sedation Information papers.




Today's Date May 16, 2022

Parent Name:

Leave this empty:

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Signature Certificate
Document name: Patient Medical History
lock iconUnique Document ID: 11b1a53856650d8e14ee2c9c361a2449d3cb57bb
Timestamp Audit
July 22, 2021 8:56 pm EDTPatient Medical History Uploaded by Pediatric Dental Anesthesia Associates - IP