Pediatric Dental Anesthesia Questionnaire

Pre-Anesthesia Pediatric Medical Questionnaire

& HIPAA Disclosure
Date*

MonthDayYear
Date
Name of the parent or person filling this form*

First NameLast Name
Cell Phone (A number we can text) *
Please enter a valid phone number.
Email*
example@example.com
Dental office *
Date of Procedure (mm/dd) or TBD*
Patient Name*

First NameLast Name
Patient Date of Birth (mm/dd/yyyy)*
Sex*

MaleFemale
Telehealth Texts

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Medical History Section

Please be as comprehensive as possible.
HIPAA stands for the Health Insurance Portability and Accountability Act ∙ HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information ∙ Information stored and transferred here are encrypted and in compliance with HIPAA. This includes our Telehealth texts, this form, our fax and email address. Please acknowledge by signing below:*

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Child Age *
Please enter your weight in Pounds and height *
Please type in all MEDICATIONS and RESPIRATORY INHARES the child is taking ; Please write in NONE of that is the case ( DO NOT include doses or frequency ) *
Please list all allergies to medications and foods *
Please list any major surgeries or recent surgeries
List any issues with Anesthesia or surgeries in the past*

Never had anesthesiaNONE - No issuesNausea / VomitingDifficult airway / Or difficult IntubationDifficult IV accessSelf or family history of Malignant HyperthermiaPseudocholinesterase DeficiencyOther
Click any of the positives below*

Check if the child exposed to second-hand smoke at home.Check if at birth was your baby Premature.Any recent illness within last 2 months (Colds, Pneumonia)None
How many weeks premature was the baby blanks .
Was the baby in the NICU and for how long: blank  .
Did the baby have to have home oxygen or have respiratory developmental delays? (Bronchopulmonary Dysplasia)    .
Any abnormalities of the tongue or vocal cords or the airway because of prolonged intubation or tracheostomy after birth?   Type a label
Any remaining issues today? Type a label
Please elaborate what type of recent illness in the last 2 months, treatments and if fully resolved.
List any Respiratory Illness (Asthma, Congenital emphysema, Sleep apnea, Cystic fibrosis, other )
List any ENT- Ear Nose Throat Illnesses ( Ear infections, abnormal tonsils causing sleep apnea, Sinus Problems , TMJ, Hoarseness, others)
List any Psychiatric / Behavioral (Anxiety, ADD, Autism, others)
List any Gastrointestinal (Acid Reflux, frequent Diarrheas, Vomiting, Jaundice, Hepatitis, difficulty swallowing)
List any Cardiac Illness (Congenital Heart defects , Rheumatic Fever , Irregular Heart Beats, Abnormal Heart Valves, others)
List any Neurologic ,Spine (Seizure , Cerebral Palsy , Spina Bifida , Numbness in hands / feet , Chiari I or II , others)
List any Congenital Developmental Disorders (Trisomy 21, Pierre Robin Syndrome, Growth disorders, any others)
List any Hematologic (Sickle Cell , Easy Bruising, Hemophilia , frequent Nose Bleeds, any others)
List any Urological (Kidney, Ureters, Bladder)
List any Musculoskeletal (Muscular Dystrophy Abnormality of spine / neck spine / Marfan's / Ehlers-Danlos syndrome, other)
List any Rheumatologic (Juvenile Rheumatoid Arthritis, other )
List any Endocrinologic (Type 1 Juvenile Diabetes , Obesity , Thyroid Problems, other )
List any Dermatologic (Eczema , other )
List any Immunodeficiency Conditions
Please add any illness now or previous or anything you would like to add
Terms and Conditions*
Signature*

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Pre-Anesthesia Pediatric Medical Questionnaire

Telehealth Texts

Medical History Section