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?

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



Today's Date October 2, 2023

Parent Name:

Leave this empty:

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Signature Certificate
Document name: Signed Patient Medical History
lock iconUnique Document ID: a5e45e3353106f2cc93649047af6a1ab8a109651
Timestamp Audit
July 22, 2021 8:56 pm EDTSigned Patient Medical History Uploaded by Pediatric Dental Anesthesia Associates - IP