twitter instagram facebook youtube linkedin connect file chain file-play search menu close file-pdf-o left right lock unlock aana connect
The latest Updates and Resources on Novel Coronavirus (COVID-19).
  • 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
    • CE Calendar of Events
    • Education
    • Program Admin Portal
    • CPC Resources - Class A & B Credits
  • 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
    • 2020 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
    • Assembly of Didactic and Clinical Educators
    • Mid-Year Assembly
    • AANA 2020 Annual Congress
    • AANA Leadership Summit
    • Ultrasound Guided PNB Workshop
    • Spinal Epidural & OB Essentials Workshop
    • State Leader Workshop - CO
    • AANA Meetings App
    • Call for Abstracts
    • CE Evaluations
    • Future Meeting and Workshop Dates
  • 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
    • Full Scope of Practice Competency Task Force
  • Publications
    • AANA Journal - Print & Online
    • Anesthesia E-ssential
    • AANA NewsBulletin
    • APSF Newsletter
    • Advertising Opportunities
    • AANA Books
    • Newsroom
  • AANA Insurance
    • Malpractice Insurance
    • Group Disability Income Insurance
    • Long-Term Care Resources
    • Individual Disability Insurance
    • Association Health Plans
    • Group Term Life Insurance Options
    • Group Accident Disability Insurance
    • Pet Insurance
  • States
    • State Association Advocacy Resources
    • State Management Affairs
    • State Associations
    • State Health and Wellness Resources
    • Toolkits for State Leaders
    • 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
  • Corporate Opportunities
    • CRNAs Transform
  • 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 - Campaign and Results
    • Foundation Applications
    • Applications and Program Information
      • Award Winners
      • General Research Grant Application
      • Open Submission Research Grant Applications
      • Fellowship Application
      • Poster Session Application
      • John F. Garde Researcher of the Year Award
      • Rita L. LeBlanc Philanthropist of the Year Award
      • Advocate of the Year Award
      • Janice Drake CRNA Humanitarian Award
        • A Message from Janice G. Drake
      • Board Nomination Application
      • Student Scholarship Application
      • AANA Foundation Health Policy Institute Program
    • 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
      • Friends for Life
      • Gertrude Fife Society
    • Events
    • Volunteer Opportunities
    • Friends for Life
  • AANA Diversity and Inclusion
    • I Am Me
    • How Harlem Hospital School of Nurse Anesthesia was Born
    • Nursing Careers and Pathways Program
  • AANA Archives-Library
    • CRNA Profiles
    • Historical Resources
    • AANA Former Presidents
    • Our History
  • AANA Careers
    • Employee Benefits
    • Staff Committees
  • Report Misrepresentation of CRNAs and CRNA Role
  • Proposed AANA Name Change - Member Information

Meetings

  • Assembly of Didactic and Clinical Educators
  • Mid-Year Assembly
  • AANA 2020 Annual Congress
  • AANA Leadership Summit
  • Ultrasound Guided PNB Workshop
  • Spinal Epidural & OB Essentials Workshop
  • State Leader Workshop - CO
  • AANA Meetings App
  • Call for Abstracts
  • CE Evaluations
  • Future Meeting and Workshop Dates

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
    • Facility Considerations
  • 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
        • Burnout and Nurse Anesthesia Professionals
        • Depression and Suicidal Ideation
      • 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
        • SRNA Substance Use Disorder Risk Videos
      • Wellness in the Workplace
        • Bullying, Disruptive Behavior, and Workplace Civility
      • State Health and Wellness Resources
        • State Health and Wellness Exhibit Toolkit
    • About AANA Peer Assistance
      • Getting Peer Assistance Help for Yourself and Others
      • Treatment Recommendations for Anesthesia Professionals
      • AANA Approved Treatment Programs
      • Meet the Peer Assistance Advisors
      • History of AANA Peer Assistance
        • Art Zwerling - In Memoriam
      • Substance Use Disorder
      • Peer Assistance News
      • Information about State Peer Advisors
      • State Peer Advisors' Toolkit
        • SPA Orientation Requirements
      • Substance Use Disorder Workplace Resources
        • Signs and Behavior of Impaired Colleagues
        • Safe Intervention E-ssentials
        • Re-entry Recommendations and Resources
        • Anesthetists in Recovery (AIR)
      • Faculty and Students: Substance Use Resources
    • AANA THRIVE
      • The Beginning
      • RN to SRNA
      • The Journey
      • Transitioning to Retirement
      • Life Challenges and Opportunities
  • Facility Accreditation
    • Accreditation Association for Ambulatory Health Care
    • Healthcare Facilities Accreditation Program
    • 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
    • Cannabis/Marijuana
    • Code of Ethics for the CRNA
    • Dental Anesthesia Resources
    • Enhanced Recovery after Surgery
      • CRNAs Contribute to ERAS Solutions
      • Role of ERAS Coordinator
      • ER SIG Webinars
    • 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
    • FDA Warns of Misbranding and Undeclared Drugs in Products
  • 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
  • Full Scope of Practice Competency Task Force

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
  • CRNA-PAC
  • Quality Reimbursement
    • Medicare Access & CHIP Reauthorization Act (MACRA)
    • 2020 Quality Payment Program
    • 2019 Quality Payment Program
      • 2019 APMs
      • 2019 Improvement Activities FAQs
      • 2019 Quality FAQs
      • 2019 Cost FAQs
      • 2019 Promoting Interoperability FAQs
    • 2018 Quality Payment Program
      • 2017 MIPS
        • MACRA Quality Payment Program
        • QCDR Infographics
    • QCDR and Registry Reporting FAQs
    • CMS Quality Public Reporting
    • Quality-Reimbursement Announcements
    • 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
    • Company Model of Anesthesia Care Delivery
    • COVID-19 State Government Resources
  • 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
    • Puerto Rico Registered Nurse Anesthetists (RNAs) Affiliation Form
  • 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
  • 2020 National CRNA Week
    • Promotional Ideas and Events
    • The Evolution of National Nurse Anesthetists Week
    • In the News
    • National CRNA Week Themes
  • Recognition Awards
    • AANA Awards
    • PR Recognition Awards Guidelines
    • Public Relations Recognition Awards-2019 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
    • Deployed CRNAs
  • In Memoriam
  • Member Communications
    • AANA FAQs about ASA Anesthesia Care Team Statement
  • 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
  • National Nurses Week
  • Volunteer Opportunities

Publications

  • AANA Journal - Print & Online
    • Past Issues: 2029 - 2020
    • Past Issues: 2019 - 2011
    • Past Issues: 2010 - 2000
    • Legal Briefs
    • AANA Journal Indexes
    • Journal Search
    • AANA Journal Online Content Archive
    • COVID-19 AANA Journal Articles
  • Anesthesia E-ssential
    • CRNA Spotlight on Ketamine
    • Anesthesia E-ssential 10th Anniversary
  • AANA NewsBulletin
    • AANA News Bulletin Search
    • Annual Business Meeting 2019
  • APSF Newsletter
  • Advertising Opportunities
  • 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
  • CE Calendar of Events
  • Education
    • Education Opportunities for Educators
    • Education Opportunities for Students
  • Program Admin Portal
  • CPC Resources - Class A & B Credits

News

  • Press Releases
    • AANA Public Relations
    • About the American Association of Nurse Anesthetists
  • Hot Topics
    • Opioid Crisis News
    • Important Nurse Anesthesia Studies
  • CRNA News Coverage
  • Anesthesia News Roundup
  • Current Events and Natural Disaster Preparedness
    • Tornado Resources

States

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

Insurance

  • Malpractice Insurance
    • Malpractice Resource Center
      • Understanding CRNA Malpractice Insurance 101
    • 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
    • Employed CRNA Toolkit
    • Contact Us
    • Will Your Assets Be Protected?
    • Malpractice Insurance in the News
    • Learn About Us
    • Policy Options
    • Additional Coverage Benefits
  • Group Disability Income Insurance
  • Long-Term Care Resources
  • Individual Disability Insurance
  • Association Health Plans
  • Group Term Life Insurance Options
  • Group Accident Disability Insurance
  • Pet Insurance

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 © 2020 American Association of Nurse Anesthetists.All rights reserved.
Cookie Settings