Microsoft word - pre-anesthetic questionnaire.doc

Pre-Anesthetic Questionnaire: DATE:__________________ 1 of 4
“CHIEF COMPLAINT”:________________________________________________
PROPOSED OPERATION:_________________________________________________HT:_____WT:______
CELL PHONE #:_______________ NO ___ YES___ DISCLOSURE ALERT
Primary Care Physician:
PLEASE LIST ALL PREVIOUS OPERATIONS OR PROCEDURE /DATE:
1_______________________________/_______ 5 _______________________________/_______ ______________________ 2_______________________________/_______ 6 _______________________________/_______ Cardiologist:( Date of last visit) 3_______________________________/_______ 7 _______________________________/_______
4_______________________________/_______ 8 _______________________________/_______ Approximate date of last Anesthetic/Surgery__________________ Have you had any problems with anesthesia? NO_______ YES_______ _______________________________ Have you been told you are difficult to intubate (insert breathing tube)? NO_______ YES_______ _____________________________ Have any blood relatives had a serious problem with anesthesia? NO_______ YES_______ ______________________________ Have you taken steroids (Cortisone, Prednisone, Hydrocortisone, or Decadron )within the past 12 months? NO_______ YES_______ ______________________________ REVIEW OF SYSTEMS:
DO YOU HAVE A HISTORY OF THE FOLLOWING MEDICAL PROBLEMS?
_____ _____ Any Heart Studies (EKG, Stress Tests, Angiogram) _____ _____ Chest Pain, Shortness of Breath If yes, Fasting Blood Sugar ________________Range ______ _____ Anemia, Easy Bruising, Free Bleeding _____ _____ Heart Murmur/Irregular Heartbeat ______ _____ Sickle Cell, Other Blood Disease _____ _____ Elevated Cholesterol, Triglycerides _____ _____ Varicose Veins, Vascular Disorders ______ _____ Stroke, Paralysis, Other Neuro Disorder _____ _____ Prev. DVT (blood clot in legs or lungs) ______ _____ Depression, Anxiety, Psych Disorder _____ _____ Asthma, Bronchitis, Emphysema, Other Lung Disease ______ _____ Back Problems, Arthritis, Swelling _____ _____ Limited Neck Motion, Pain, or Injury _____ _____ Jaw Clicking, Pain or Stiffness _____ _____ Ulcerative Colitis, Crohn’s Disease, IBS _______ _____ History of Multi Drug Resistant Organism _____ _____ Previous colonoscopy, hx colon polyps (MRSA, VRE, etc.) _____ _____ Family history colon cancer ______ _____ Headaches or Recent Visual Changes _____ _____ Nausea, Vomiting (Persistent) ______ _____ Cancer, Immunosuppression, Chemotherapy Indigestion, Ulcers, Reflux, Hiatal Hernia ______ _____ Breathing difficulties when lying flat _____ _____ Facial Plastic or Reconstructive Surgery ______ _____ Sleep Apnea. If yes, CPAP machine used?__ ______ _____ Family History of Heart Disease
Other:____________________________________________________________________________________________________
Do you frequently awaken with numbness in an arm or leg? NO_____ YES_____ Are you Pregnant? NO_____ YES_____ Not Sure_____ Not Applicable_____ Date of last menstrual period________________ Are you Right handed?_____ Left handed?______ Do you wear contact lenses? NO_____ YES_____ NOTE: If yes, please remove them before surgery. Do you have Capped Teeth / Crowns__________ Loose Teeth___________ Bridges___________ Dentures/Partials_____________ Do you have Advance Directives/ Living Will? NO _________ YES _________ (If YES, please have patient bring copy, if possible) SOCIAL HISTORY
Occupation:_______________________________ What type of exercise do you get?__________________________________________ Do/Did you smoke? NO_____ YES_____ Packs Per Day______ How many Years?___________ Quit when?____________________ What is your alcohol consumption?_________________________________________________________________________________ Do/Did you have a problem with drug or alcohol dependence/addiction?____________________________________________________ Do you have a religious objection to blood transfusion? NO_____ YES_____
PATIENT SIGNATURE
____________ VERIFIED BY:_________________________RN TIME:__________

Source: http://www.fairwaymedical.com/Files/Press/PRE-ANESTHETICQUESTIONNAIRE.pdf