Pediatric Sedation Dental History
Patient Information
Child's Name
Date of Birth
Age
Parent/Guardian Name
Contact Number
Medical History
Primary Physician
Weight (kg)
Height (cm)
Allergies
Current Medications
Medical Conditions
Asthma
Heart Disease
Seizures
Diabetes
Bleeding Disorders
Other Medical Conditions
Sedation History
Previous Sedation or Anesthesia?
Yes
No
If yes, please describe
Any complications during previous sedation or anesthesia?
Yes
No
If yes, please describe
Dental History
Reason for Visit
Previous Dental Experiences
Has the child experienced any of the following? (check all that apply)
Dental Pain
Swelling
Bleeding Gums
Dental Trauma
Other Dental Issues
Additional Comments