Form Hp9 - Ummc Preoperative And Preanesthetic Patient Questionnaire Form Page 2
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4Patient Name: ________________________________ Date of Birth: __________________
6. Do you have any allergies to medications?
Yes
No
(circle)
Drug: ________________________ What happens? __________________________
Drug: ________________________ What happens? __________________________
Drug: ________________________ What happens? ______________________________
Drug: ________________________ What happens? ____________________________
7. Do you have any allergies to substances other than medications? Yes
No
(circle)
(Circle all that apply)
Betadine/Iodine
Latex
Eggs
Other: ______________
Gadolinium
IV contrast
Tape
8. List all the surgeries you have had in the past (most recent first).
(Use back of page for additional information)
Year: ____________ Surgery: ______________________ Hospital: ____________________
Year: ____________ Surgery: ______________________ Hospital: ____________________
Year: ____________ Surgery: ______________________ Hospital: ____________________
Year: ____________ Surgery: ______________________ Hospital: ____________________
9. Have you or anyone related to you ever had a major
Yes
No
(circle)
complication that was related to receiving anesthesia?
10. Have you had blood drawn for testing in the past three months? Yes
No
(circle)
Date: ____________ Place: __________________________________________________________
11. Have you had a chest x-ray in the past year?
Yes
No
(circle)
Date: ____________ Place: __________________________________________________________
12. Have you ever had an EKG done?
Yes
No
(circle)
Date: ____________ Place: __________________________________________________________
Date: ____________ Place: __________________________________________________________
13. Have you ever had any heart problems (for example,
Yes
No
(circle)
congestive heart failure, angina (chest pain), heart attack, arrhythmia)?
Date: ____________ Problem: __________________________ Hospital: ____________________
Date: ____________ Problem: __________________________ Hospital: ____________________
Date: ____________ Problem: __________________________ Hospital: ____________________
14. Do you have an Automatic Internal Cardiac Defibrillator
Yes
No
(circle)
(AICD) or pacemaker?
If “Yes”, do you know the model and the name of the maker?
Model __________ Company ______________________________________________________
(Please bring your device pocket card with you to the hospital.)
15. Have you ever had any special heart tests? (for example, stress tests, echocardiograms,
cardiac catheterization)
Yes
No
(circle)
Date: ____________ Test: ________________________ Place: ________________________
Date: ____________ Test: ________________________ Place: ________________________
Date: ____________ Test: ________________________ Place: ________________________
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HP9 (effec. 04/07)
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Parent category: Medical