Anesthesia Questionaire

Hi All: I found this and thought it would be helpful to us 'pre ops'. I printed mine and will make sure all of it is gone over before the big day. ~Tina~ Preanesthesia Questionnaire The information you supply below assists in the development of your anesthesia care. Please complete this questionnaire accurately and completely. Patient Name _________________________________________ Age _________ Weight _______ Height _________ Date ____________ Allergies _______________________________________________ ________________________________________________________ Current Medications (Prescription and Non-Prescription)______ ________________________________________________________ Prior Operations _________________________________________ _________________________________________________________ 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? [ ] [ ] 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 or 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 _____________.

hay.. cool thanks

Hello, Tina Thank You so much for that information Lorrie

The hospital called me on Friday and asked me all of those questions and more and part of my pre-admission. I guess that cuts down on the paperwork that I fill out when I get there. I appreciate that so much because once I get there Wednesday morning, I want to get the ball rolling LOL