Signed Patient Medical History
Has this patient or any other family members been a patient of PDAA previously?
Date Of Birth:
Child's Height (if known):
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?
How many minutes is your drive from home to the dental office?
Today's Date March 24, 2023
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Signed Patient Medical History
Agree & Sign