Form Hp9 - Ummc Preoperative And Preanesthetic Patient Questionnaire Form
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UMMC Preoperative and Preanesthetic Patient Questionnaire
Date Completed:__________________________
Dear Patient,
This questionnaire will help your anesthesia team determine what if any preoperative work up will be
needed prior to your surgery and help them gather all available medical information about you. Please fill
it out as best you can. This information will help to avoid any delay in your surgery.
In some cases, we will contact you to schedule an appointment for a preoperative evaluation either in the
PREP center (at the University of Maryland Medical Center) or we will contact you for a preoperative
evaluation over the phone. If you have any questions, you can contact us at 410-328-5750 . Thank you!
Name: ______________________________ Person Completing Form: ____________ Title: ________
Age: ____________ Height: ______________ Weight: ______________ Date of Birth: __________
Surgeon: ______________________________ Proposed Surgery: __________________________
Proposed date of surgery: ____________________
1. Your contact information:
Home phone:
__________________________Work phone:
________________________
Cell phone or pager: ____________________ E-mail address: ______________________
Best time to reach you:
AM
PM
(circle)
Best way to reach you:
home
work
cell/pager
e-mail
(circle)
2. Do you have a primary care doctor?
Yes
No
(circle)
Name: ____________________________________________________________________
Address and phone number: ________________________________________________________
3. Do/Did you ever smoke?
Yes
No
(circle)
How many packs per day? ____________________________
How many years? ______________________________
If applicable, when did you quit? __________________
4. Do/Did you ever drink alcohol?
Yes
No
(circle)
How often?________________________________________
How much? ________________________________________
If applicable, when did you quit? __________________
5. Do/Did you ever use “street” drugs?
Yes
No
(circle)
What drug? (circle) Cocaine Heroin Other: ________
Did you ever use IV drugs?
Yes
No
(circle)
If applicable, when did you quit? __________________
Please use the last page of this questionnaire to list all your medications, including over-the-
counter herbals and vitamins, as well as “as needed” medications.
Please fax forms to 410-328-8125 for review when completed.
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HP9 (effec. 04/07)
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