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Requested Medical History - {{cf7-field-id-patient-first-name}} {{cf7-field-id-patient-last-name}}

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 March 18, 2025

Parent Name:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

February 18, 2025 1:29 pm EDT

Requested Medical History - {{cf7-field-id-patient-first-name}} {{cf7-field-id-patient-last-name}} Uploaded by Digital Neighbor - [email protected] IP 73.149.139.193

February 18, 2025 1:31 pm EDT

PDAA Medical History - [email protected] added by Pediatric Dental Anesthesia Associates - [email protected] as a CC'd Recipient Ip: 74.97.52.218

February 18, 2025 4:12 pm EDT

PDAA Medical History - [email protected] added by Pediatric Dental Anesthesia Associates - [email protected] as a CC'd Recipient Ip: 74.97.52.218

February 24, 2025 3:32 pm EDT

Document owner [email protected] has handed over this document to [email protected] 2025-02-24 15:32:52 - 73.149.139.193

February 24, 2025 3:32 pm EDT

PDAA Medical History - [email protected] added by Digital Neighbor - [email protected] as a CC'd Recipient Ip: 73.149.139.193

February 25, 2025 9:23 am EDT

PDAA Medical History - [email protected] added by Digital Neighbor - [email protected] as a CC'd Recipient Ip: 73.149.139.193