twitter instagram facebook youtube linkedin connect file chain file-play search menu close file-pdf-o left right lock unlock aana connect
  • CRNA Careers
  • Governance
  • Donate
  • Patients
  • Contact Us
  • CRNA-PAC
  • Store
  • About Us
Welcome,
  • Log Out
  • Renew Membership
  • My Account
  • My Clinical Profile
MyAANA
Join / Renew
Safe and effective anesthesia care
for every patient
Menu
Close
  • CE & Education
    • AANA Learn
    • CE Transcripts
    • CE Portal
    • AANA CE Applications
    • Pain Management
    • CPC Resources - Class A & B Credits
    • CE Calendar of Events
    • Education
    • Program Admin Portal
  • Advocacy & Policy
    • Federal Government Affairs
    • CRNA-PAC
    • Quality Reimbursement
    • State Government Affairs
    • Research
  • Member Resources
    • Membership Benefits
    • Member Advantage Program
    • CRNA Careers
    • Students
    • Become A CRNA
    • National CRNA Week
    • Recognition Awards
    • In Service of Our Country
    • In Memoriam
    • Member Communications
    • Renew Membership
    • CRNA Fact Sheet
    • Public Relations
    • National Nurses Week
    • Volunteer Opportunities
  • Meetings
    • Future Meeting and Workshop Dates
    • AANA Meetings App
    • Call for Abstracts
    • CE Evaluations
  • Practice
    • Practice Management
    • Health and Wellness/Peer Assistance
    • Facility Accreditation
    • Professional Practice Manual
    • Clinical Practice Resources
    • Evidence-Based Practice
    • U.S. Food and Drug Administration
    • State Law and Practice
  • Publications
    • AANA Journal - Print & Online
    • Anesthesia E-ssential
    • AANA NewsBulletin
    • APSF Newsletter
    • Advertising Opportunities
    • Congress Daily
    • Building Brydges
    • AANA Books
    • Newsroom
  • Insurance
    • Get Quote
    • My Policy (Apply for Coverage, Renew, or Review Your Policy)
    • Policy Options
    • Learn About Us
    • Malpractice Insurance in the News
    • Will Your Assets Be Protected?
    • Contact Us
    • Employed CRNA Toolkit
    • Resource Center
    • Malpractice Resource Center
    • Association Health Plans
  • States
    • State Association Advocacy Resources
    • State Management Affairs
    • State Associations
    • State Health and Wellness Resources
    • Toolkits for State Leaders
    • State Membership Statistics
    • Webinars for State Leaders
  • Home
  • Patients
  • Pre-Anesthesia Questionnaire

Pre-Anesthesia Questionnaire

The Pre-Anesthesia Questionnaire is used to help prepare you for the anesthesia process and assists in the development of your anesthesia care plan.

Please print and fill out the PDF below as accurately and completely as possible.

  • Pre-Anesthesia Questionnaire

 

 

In This Section: Patients
  • All About Anesthesia
    • Before Anesthesia
    • After Anesthesia
    • Anesthetic Awareness
      • Anesthetic Awareness Fact Sheet
    • Anesthesia Options for Labor and Delivery
    • Questions You Should Ask
  • The Parent's Role
    • Is Your Child at Risk from Sleep-Disordered Breathing?
    • Sweet Dreams at the Hospital Coloring and Activity Book
  • Be Healthy: Stop Smoking
  • Herbal Products and Your Anesthesia
  • Time to Talk about CAM
  • AANA Warns Viagra Users of Potential Risks During Surgery
  • Anesthesia Risks of Tattoos and Pierced Tongues: More Than Skin Deep
  • Holiday Surgery Tips
  • MRI: What You Need to Know
  • Office-Based Anesthesia
  • Pre-Anesthesia Questionnaire
  • Does Anesthesia Affect a New Mom’s Ability to Breastfeed?
  • Opioid Addiction Help Fact Sheet

American Association of Nurse Anesthetists

  • AANA Connect
  • View our Facebook page.
  • View our Twitter feed.
  • View our Instagram feed.
  • View our YouTube channel.
  • View our LinkedIn profile.

222 S. Prospect Avenue, Park Ridge, IL 60068-4037

Phone: 847-692-7050Fax: 847-692-6968

About Us

  • Who We Are
  • AANA Board of Directors
  • Committees
    • Bylaws Committee
    • Communications Committee
    • Continuing Education Committee
    • CRNA-PAC Committee
    • Diversity and Inclusion Committee
    • Education Committee
    • Finance Committee
    • Government Relations Committee
    • Health and Wellness Committee
    • Journal Editorial Committee
    • Nominating Committee
    • Peer Assistance Advisors Committee
    • Practice Committee
    • Professional Development Committee
    • Resolutions Committee
    • State Organizational Development Committee
    • Committee Membership Information for CRNAs
    • Committee Membership Information for Students
  • AANA Staff Directors
  • Cultural Assessment
  • Corporate Opportunities
  • AANA Affiliates
    • Council on Accreditation
    • COA For Members
  • AANA Foundation
    • About the Foundation
    • Ways to Give to the AANA Foundation
      • Silent Auction
      • Triple Crown
    • RISE Above
    • Foundation Applications
    • Applications and Program Information
      • Award Winners
      • General Research Grant Application
      • Open Submission Research Grant Applications
      • Fellowship Application
      • Poster Session Application
      • Student Scholarship Application
    • Advocates
      • Tips and Ideas
    • Health Policy Research
      • Intro to Health Services Research
    • Publications
    • About Us
    • Discoveries of Distinction
    • Student Page
      • Student Advocates
      • Past Student Advocates
    • Impact and Accomplishments
    • Our Supporters
    • Events
  • AANA Diversity and Inclusion
    • I Am Me
  • AANA Archives-Library
    • CRNA Profiles
    • Historical Resources
    • AANA Former Presidents
    • Our History
  • AANA Careers
    • Employee Benefits
    • Staff Committees

Meetings

  • Future Meeting and Workshop Dates
  • AANA Meetings App
  • Call for Abstracts
  • CE Evaluations

Practice Topics

  • Practice Management
    • Business of Anesthesia
    • Employment Resources
    • Pain Management
    • AANA Member Business Resources
    • AANA Business Resources
    • Surgeon Liability
    • Protecting Your Practice: Compliance and Enforcement for CRNAs
  • Health and Wellness/Peer Assistance
    • About Health & Wellness
      • Emotional and Mental Well-Being
        • Post Traumatic Stress Disorder (PTSD)
        • Adverse Medical Events/Critical Incidents - How to Cope
        • Stress and Nurse Anesthesia Professionals
      • Physical Well-Being
      • Wellness Milestones
      • Wellness and Substance Use Disorder Education and Research
        • Research and Published Resources on Anesthesia Professionals' Health, Wellness, and Addictions
        • Wellness and Substance Use Disorder Curriculum
          • NIH YouTube Channel
        • Jan Stewart Memorial Wellness Lecture Series
          • Jan Stewart In Memoriam
      • Wellness in the Workplace
    • About AANA Peer Assistance
      • Getting Peer Assistance Help for Yourself and Others
      • Meet the Peer Assistance Advisors
      • History of AANA Peer Assistance
        • Art Zwerling - In Memorium
      • Information about State Peer Advisors
      • State Peer Advisors' Toolkit
        • SPA Orientation Requirements, Part I & II
      • Substance Use Disorder
      • Peer Assistance News
      • Substance Use Disorder Workplace Resources
        • Signs and Behavior of Impaired Colleagues
        • Safe Intervention E-ssentials
        • Treatment Recommendations for Anesthesia Professionals
        • Re-entry Recommendations and Resources
        • Anesthetists in Recovery (AIR)
      • Faculty and Students: Substance Use Resources
  • Facility Accreditation
    • Accreditation Association for Ambulatory Health Care
    • Accreditation Association for Hospitals/Health Systems and Healthcare Facilities Accreditation Program
    • American Association for Accreditation of Ambulatory Surgery Facilities
    • Center for Improvement in Healthcare Quality
    • DNV GL Healthcare
    • The Joint Commission
  • Professional Practice Manual
    • Open Comments
  • Clinical Practice Resources
    • Dental Anesthesia Resources
    • Enhanced Recovery after Surgery
      • Enhanced Recovery Shared Interest Group Pilot
      • CRNAs Contribute to ERAS Solutions
      • Role of ERAS Coordinator
    • Infection Prevention and Control Resources
      • Enhancing Education and Training on Infection Control for U.S. Nurses
    • Ketamine Infusion Therapy
    • Malignant Hyperthermia
    • Obstetric Clinical Resources
    • Obstructive Sleep Apnea Resources
    • Opioid Crisis Resources
      • CRNAs and Medication-Assisted Treatment (MAT)
      • Opioid Crisis Data
      • Opioid Safety Resources
      • Managing Chronic Pain
      • Opioid Comment Letters
      • Prescription Medicine Disposal
      • Opioid Safety and Advocacy State Toolkit
    • Sugammadex
    • Surgical Fires
  • Evidence-Based Practice
    • Step 1 - Ask A Clinical Question
    • Step 2 - Obtain the Best Research Literature
    • Step 3 - Critically Appraise the Evidence
    • Step 4 - Integrate the Evidence
    • Step 5 - Evaluate the Outcomes
  • U.S. Food and Drug Administration
    • U.S. Food and Drug Administration Alerts
    • IV Saline Solution
    • Street Drug Alternative Warning
  • State Law and Practice
    • Negotiation and Dispute Resolution Resources
    • Medicare Agency Rules in Favor of Patient Access to CRNA Care
    • Safe Injection Practices and Criminalization of Reuse
    • Office Surgery and Anesthesia
    • Working with Podiatrists or Dentists

Advocacy & Policy

  • Federal Government Affairs
    • Medicare Agency Rules in Favor of Patient Access to CRNA Care
    • Medicare CoPs and Interpretive Guidelines
    • Comment Letters
    • Veterans and Anesthesia Care
    • Member Resources
      • CoP and Interpretive Guidelines
      • CRNA Advocacy and CRNA-PAC
      • Hotline
      • Medical Direction vs. Medicare Part A Supervision
      • State Reimbursement Specialist
  • CRNA-PAC
  • Quality Reimbursement
    • Quality Payment Program
      • 2017 MIPS
        • Medicare Access & CHIP Reauthorization Act (MACRA)
        • MACRA Quality Payment Program
        • QCDR Infographics
      • 2018 Quality FAQs
      • 2018 Improvement Activities FAQs
    • QCDR and Registry Reporting FAQs
    • CMS Quality Public Reporting
    • Quality-Reimbursement Announcements
    • 2016 PQRS
      • 2016 Physician Quality Reporting System (PQRS)
      • PQRS Feedback Reports and Payment Adjustments
      • Value Based Modifer (VM)
    • Quality Resources
  • State Government Affairs
    • SGA Member Resources
      • State Update
      • Contact Information for State Legislators
      • State Advocacy Videos
      • Anesthesiologist Assistants
        • AANA Position on AAs
        • AANA Position on CRNAs Teaching AA Students in the Clinical Setting
      • Anesthesia: Practice of Nursing and Practice of Medicine
    • State Legislative and Regulatory Requirements
    • Federal Supervision Rule/Opt-Out Information
      • Fact Sheet Concerning State Opt-Outs
    • Anesthesia: Practice of Nursing and Practice of Medicine
    • Award for Excellence in State Government Relations Advocacy
  • Research
    • Research Topics and Articles
    • Research Surveys, Services and Assistance
    • External Opportunities and Research News
    • AANA Foundation Funding Opportunities
    • Research Resources
      • Hot Research Topics
      • Research Abstract Repository
      • Health Services Research Webinar Series
      • Research Dataset Resources

Member Resources

  • Membership Benefits
    • Membership Automatic Renewal Policy
    • Membership Categories and Privileges
  • Member Advantage Program
  • CRNA Careers
  • Students
    • Student Membership
    • Opportunities for Students
    • International Student Journal of Nurse Anesthesia
    • Anesthesia College Bowl
    • Candidates for Student Representative to the AANA Education Committee
    • Student Wellness
    • Informational Videos for SRNAs
  • Become A CRNA
    • Education of Nurse Anesthetists in the U.S.
    • The Nurse Anesthesia Educational Program Interview Process
    • Qualifications and Capabilities of the CRNA
    • Why I Became a CRNA
  • National CRNA Week
    • Promotional Ideas and Events
    • The Evolution of National Nurse Anesthetists Week
    • In the News
  • Recognition Awards
    • AANA Awards
    • PR Recognition Awards Guidelines
    • Public Relations Recognition Awards-2018 Entries
  • In Service of Our Country
    • Celebrating Veterans and Their Service on Veterans Day
    • A Tranquil Place of Honor
    • Vietnam Voices
      • Voices of Vietnam: Ernest Ayo Photos
    • War Stories
    • War Stories News
  • In Memoriam
  • Member Communications
  • Renew Membership
  • CRNA Fact Sheet
  • Public Relations
    • PR Tools and Resources
    • Public Education Campaign
    • PR Toolkit
    • Power of the Pen News Releases
    • PR Tools: National CRNA Week
    • PR Tools: Message Documents and Fact Sheets
    • PR Tools: Educational Opportunities, Activities and Events
    • PR Tools: News and Social Media
    • Social Media for National CRNA Week
    • Media Alerts
    • Spokesperson Training for State Association Leaders
    • Student Mentoring Program
    • PowerPoint Presentations
    • Public Relations Posters
    • AANA Communications Committee Recognizes MYA Student Mentoring Program Participants
    • Members Gather to Hear the State of the Association at the Annual Business Meeting
  • National Nurses Week
  • Volunteer Opportunities

Publications

  • AANA Journal - Print & Online
    • Past Issues: 2018 - 2011
    • Past Issues: 2010 - 2000
    • Legal Briefs
    • AANA Journal Indexes
    • Journal Search
    • AANA Journal Online Content Archive
  • Anesthesia E-ssential
    • CRNA Spotlight on Ketamine
  • AANA NewsBulletin
  • APSF Newsletter
  • Advertising Opportunities
  • Congress Daily
    • Congress Daily - Pre-Issue 1
    • Congress Daily - Pre-Issue 2
    • Congress Daily - Sunday, September 23, 2018
    • Congress Daily - Monday, September 24, 2018
    • Congress Daily - Tuesday, September 25, 2018
  • Building Brydges
  • AANA Books
  • Newsroom

Continuing Education

  • AANA Learn
  • CE Transcripts
  • CE Portal
  • AANA CE Applications
    • Prior Approval Application
    • Non-Prior Approval Applications
  • Pain Management
    • Advanced Pain Management Fellowship Program
    • Acute Surgical Pain Management Fellowship
  • CPC Resources - Class A & B Credits
  • CE Calendar of Events
  • Education
    • Education Opportunities for Educators
    • Education Opportunities for Students
  • Program Admin Portal

News

  • Press Releases
    • AANA Public Relations
    • About the American Association of Nurse Anesthetists
  • Hot Topics
    • VA Full Practice Authority News
    • Opioid Crisis News
  • CRNA News Coverage
  • Anesthesia News Roundup
  • Important Nurse Anesthesia Studies
  • Current Events and Natural Disaster Preparedness
    • Hurricane Florence Resources
    • Hurricane Michael Resources
    • Wildfire Resources

States

  • State Association Advocacy Resources
  • State Management Affairs
  • State Associations
  • State Health and Wellness Resources
  • Toolkits for State Leaders
  • State Membership Statistics
  • Webinars for State Leaders

Insurance

  • Get Quote
  • My Policy (Apply for Coverage, Renew, or Review Your Policy)
  • Policy Options
  • Learn About Us
  • Malpractice Insurance in the News
  • Will Your Assets Be Protected?
  • Contact Us
  • Employed CRNA Toolkit
  • Resource Center
    • Understanding CRNA Malpractice Insurance for Members
    • Insurance FAQs
    • Glossaries
    • Risk Management and Patient Safety
    • AANA Insurance Services NewsBulletin Articles
    • Program Director Malpractice Insurance Toolkit
  • Malpractice Resource Center
    • Understanding CRNA Malpractice Insurance 101
  • Association Health Plans

Patients

  • All About Anesthesia
    • Before Anesthesia
    • After Anesthesia
    • Anesthetic Awareness
      • Anesthetic Awareness Fact Sheet
    • Anesthesia Options for Labor and Delivery
    • Questions You Should Ask
  • The Parent's Role
    • Is Your Child at Risk from Sleep-Disordered Breathing?
    • Sweet Dreams at the Hospital Coloring and Activity Book
  • Be Healthy: Stop Smoking
  • Herbal Products and Your Anesthesia
  • Time to Talk about CAM
  • AANA Warns Viagra Users of Potential Risks During Surgery
  • Anesthesia Risks of Tattoos and Pierced Tongues: More Than Skin Deep
  • Holiday Surgery Tips
  • MRI: What You Need to Know
  • Office-Based Anesthesia
  • Pre-Anesthesia Questionnaire
  • Does Anesthesia Affect a New Mom’s Ability to Breastfeed?
  • Opioid Addiction Help Fact Sheet

AANA® is a registered trademark of the American Association of Nurse Anesthetists
Privacy Policy. Copyright © 2018 American Association of Nurse Anesthetists.All rights reserved.
Cookie Settings