Pre-Anesthesia Questionnaire

The information you supply below assists in the development of your anesthesia care plan.
Please complete this questionnaire accurately and completely.


Patient Name ___________________________________________________


Age _________   Weight _______   Height _________     Date _____________


Allergies _______________________________________________________

_______________________________________________________________


Current Medications (Prescription and Non-Prescription -- include all
over-the-counter  medications; herbal supplements; complementary or alternative
medicines)______________________________________________________

_______________________________________________________________


Prior Operations _________________________________________________

_______________________________________________________________

 

 

Pre-Anesthesia Questionnaire

Please answer the following questions. These responses will help us provide
the anesthetic that is best for you.

 

Yes No

Question

[   ] [   ]    Have you recently had a cold or the flu?
[   ] [   ]    Are you allergic to latex (rubber) products?
[   ] [   ]    Have you experienced chest pain?
[   ] [   ]    Do you have a heart condition?
[   ] [   ]    Do you have hypertension (high blood pressure)?
[   ] [   ]    Do you experience shortness of breath?
[   ] [   ]
   Do you have asthma, bronchitis, or any
   other breathing problem?
[   ] [   ]
   Do you (or did you) smoke?
Packs/day _____.  Number of years _____.
Date you quit _____________.
[   ] [   ]
   Do you consume alcohol?
Drinks/week _________.
[   ] [   ]    Do you take or have you taken recreational drugs?
[   ] [   ]    Do you take herbal supplements, or complementary / alternative medicines? How recently?
[   ] [   ]    (Men) Do you take or have you taken Viagra, Cialis, or other erectile disfunction medicines?
[   ] [   ]    Have you taken cortisone (steroids) in the last six months?
[   ] [   ]    Do you have diabetes?
[   ] [   ]    Have you had hepatitis, liver disease, or jaundice?
[   ] [   ]    Do you have a thyroid condition?
[   ] [   ]    Do you have or have you had kidney disease?
[   ] [   ]    Do you have ulcers or other stomach disorders?
[   ] [   ]    Do you have a hiatal hernia?
[   ] [   ]    Do you have back or neck pain?
[   ] [   ]    Do you have numbness, weakness, or paralysis of your extremities?
[   ] [   ]    Do you have any muscle or nerve disease?
[   ] [   ]    Do you or any of your family have sickle cell trait?
[   ] [   ]    Have you or any blood relatives had difficulties with anesthesia?
[   ] [   ]    Do you have bleeding problems?
[   ] [   ]    Do you have loose, chipped, false teeth, or bridgework?
[   ] [   ]    Do you have any oral piercings, (such as studs or rings) in your tongue or lip?
[   ] [   ]   Do you wear contact lenses?
[   ] [   ]   Have you ever received a blood transfusion?
[   ] [   ]
  (Women) Are you pregnant? Due date ____________.
 
 
 
For an English and/or Spanish copy of an informed consent form, see the Professional Practice Manual.