Animas Pediatric Dental Group, PC
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ANIMAS PEDIATRIC DENTAL GROUP, P.C. www.animaspediatricdentistry.com 2650 E. Pinon Frontage Rd. Bldg. 200 • Farmington, NM 87402 • (505)599-9359 • Fax: (505)599-8177 DOUG HOLMES, D.D.S, M.S. LAWRENCE E. SUAZO, D.D.S. History and Physical Examination for In-Office Dental Conscious Sedation Patient Name: ________________________________________ DOB: ______/______/______ Chief Complaint: ____Dental Caries____________ Present Illness: ________________________ Current Medications: _____________________________________________________________ Previous Medical History : (Including allergies or reactions to medications) None/ Date and Type: _____________________________________________________ Family History: No significant family history FH significant for: _________________________________________________________ Review of symptoms: No significant problems Significant ROS problems: __________________________________________________ Physical Exam: Vital Signs: Ht _________ Wt ________ BP _____/______ P ______ T ______ HEENT Neck Chest Heart Abdomen Extremities Neurological Airway Assessment WNL _____ WNL _____ WNL _____ WNL _____ WNL _____ WNL _____ WNL _____ WNL _____ Comments __________________________ Comments __________________________ Comments __________________________ Comments __________________________ Comments __________________________ Comments __________________________ Comments __________________________ Comments __________________________ Impressions and recommendations: (Include ASA Classification) ___________________________ ___________________________ Date ____________________________________ Signature of Provider ___________________________ Office Phone ____________________________________ Printed Name
