Patient Health/Anesthesia Questionnaire

Type of Operation

Surgeon

Patient Name *

Date of Birth

Age

Phone Number

Occupation

Marital Status

• Married
• Divorced
• Single
• Widowed

Children

Height

• Feet
• CM

Height

Weight

• KG
• LBS

Weight

Family Physician

Family Physician phone #

Do you have any ALLERGIES?

• No
• Yes

Have you ever had Anesthetic?

• No
• Yes

Are you pregnant or do you think you could be pregnant?

• No
• Yes

Date of Last menstrual Period

Do you have any Loose teeth, Caps, Crowns, Bridges, Dentures or other removable Dental Appliances?

• No
• Yes

Have you ever Smoke?

• No
• Yes

Any cough?

• No
• Yes

Do you take, or have you ever taken any ADDICTING DRUGS?

• No
• Yes

How much alcohol do you drink in a week?

Angina or chest pain

• No
• Yes

Chest pain climbing one flight of stairs or / at night

• No
• Yes

Heart attack / Heart Failure

• No
• Yes

High blood pressure

• No
• Yes

Palpitations / Irregular pulse / Heart murmur

• No
• Yes

Pacemaker / Internal Defibrillator (ICD)

• No
• Yes

Bypass surgery /Angioplasty / Stent

• No
• Yes

Valve replacement / Heart transplant

• No
• Yes

Stroke / TIA

• No
• Yes

Peripheral Vascular Disease e.g. DVT, phlebitis, blood clot, aortic aneurysm, arterial or carotid bypass surgery

• No
• Yes

Aspirin, Coumadin, Plavix, other Blood Thinners

• No
• Yes

Asthma

• No
• Yes

Chronic bronchitis / emphysema / COPD

• No
• Yes

Sleep apnea (heavy snoring, choking, use of CPAP)

• No
• Yes

Shortness of breath climbing one flight of stairs or/at night

• No
• Yes

Tuberculosis

• No
• Yes

Any other lung problems

• No
• Yes

Diabetes

• No
• Yes

Liver Disease / Hepatitis

• No
• Yes

Sickle Cell Disease/Trait/or Family History of Anemia

• No
• Yes

Easy bleeding or bruising

• No
• Yes

Thyroid Problems

• No
• Yes

Muscular Dystrophy, Epilepsy/Seizure, Polio

• No
• Yes

Kidney problems

• No
• Yes

Acid reflux or frequent heartburn / Ulcer / Hiatus Hernia

• No
• Yes

Rheumatoid arthritis / Aankylosing spondylitis

• No
• Yes

Chronic Neck / Back / Muscle Injury or Problems

• No
• Yes

Have you taken Prednisone / Steroid medication in the last 6 months?

• No
• Yes

Have you ever had a blood transfusion?

• No
• Yes

Do you or have you ever had any serious illness (Cancer, Chemotherapy etc) not mentioned?

• No
• Yes

Do you have any past surgeries?

• No
• Yes

Are you taking any medications including over-the-counter drugs, puffers, insulin:

• No
• Yes

List of Medication

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• By initiating this form, I confirm that my answers are true and have been answered to the best of my ability.

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