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