Form Hp9 - Ummc Preoperative And Preanesthetic Patient Questionnaire Form Page 3
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4Patient Name: ________________________________ Date of Birth: __________________
16. Can you climb one flight of stairs without stopping?
Yes
No
(circle)
17. Please describe your physical activities. (i.e. exercise often, run regularly, play tennis, able
to mow lawn, poor exercise tolerance, get short of breath frequently, mostly sitting down
throughout the day) ____________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
18. Have you ever had a lung function test (spirometry)?
Yes
No
(circle)
Date: ________________ Place: ______________________________________________________
19. Have you ever been diagnosed with any of the following (circle all that apply):
Peripheral vascular disease Bleeding or clotting problems Stroke or mini stroke
Kidney disease
Asthma
Tuberculosis
Emphysema
GERD/Reflux/Heartburn
Hiatal hernia
Cancer
Hepatitis
Cirrhosis
Seizure
Diabetes
Thyroid problems
HIV/AIDS
High Blood Pressure
20. Specialists you are currently seeing or have seen in the past five years:
(You do not need to list your surgeon for the proposed procedure here).
Cardiologist Name: __________________________________ Phone: __________________
Pulmonologist Name: __________________________________ Phone: __________________
Nephrologist Name: __________________________________ Phone: __________________
Hematologist Name: __________________________________ Phone: __________________
Oncologist Name: ______________________________________ Phone: __________________
Other Name: ____________________ Specialty: ____________ Phone: ____________________
Other Name: ______________________ Specialty: ____________ Phone: ____________________
21. Have you been diagnosed with obstructive sleep apnea?
Yes
No
(circle)
Do you use CPAP/BiPAP?
Yes
No
(circle)
Have you had a sleep study?
Yes
No
(circle)
Date: ________ Place: ________________________________
22. Are there any specific things you would like your anesthesiologist to know?
__________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
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HP9 (effec. 04/07)
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