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Signed Patient Medical History

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

Patient's Name

Gender:

Age:

Date Of Birth:

Parent's Name:

Child's Height (if known):

Child's Weight:

Home #:

Work #:

Cell #:

Dentist:

Does your child take any medications?
Does anyone smoke in your child’s home?
Allergies
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 January 16, 2025

Parent Name:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

July 22, 2021 8:56 pm EST

Signed Patient Medical History Uploaded by Pediatric Dental Anesthesia Associates - billing@pediatricsedation.com IP 74.97.51.60