Patient Checklist, Medication List And Anesthesia Questionnaire (Page 2 of 3) in pdf

rev. 5/2013

CENTER FOR SURGERY OF ENCINITAS

Anesthesia Questionnaire

Reviewers Initials:

Patient Name:_________________________________________

Date_____________

_____________

Weight___________

Height_____________

Age__________

Physical Activity Now: Little________Moderate________Active________Very Active________

Can you climb stairs?

Yes_________No_______

More than one flight_________

YOUR ANESTHESIA HISTORY

What kind of anesthesia have you had? (circle all that apply)

General (Pentotal/Gas)

Saddle Block/Spinal

Nerve blocks Local injections

YES NO

Have you or your family had any reactions, problems, or complications with anesthesia?

Are you allergic to Latex?

Have you been treated at this facility before?

Have removable dentures, caps, loose or chipped teeth?

Wear contact lenses, false eyelashes, false eyes?

Have difficulty opening your mouth or moving your head or neck?

YOUR MEDICAL HISTORY

(IF ANSWER IS YES, CIRCLE ALL THAT APPLY)

YES NO

Bleeding Tendency,

Hepatitis

Jaundice

Liver Trouble

Lung Disease

Asthma

Wheezing

Bronchitis

Emphysema

Do you currently have a

Cough

Cold

Heart Disease Heart Attack-when? ________ Angina Chest Pain Irregular heart beat-what kind?_______

Stroke-when________

Epilepsy

Convulsions

Mental illness

Nerve Paralysis

Fainting Spell

High Blood Pressure

Diabetes

Thyroid Disease

Glaucoma

Sickle Cell Anemia

Present Drug Addiction

List Drug(s)__________________

Have you taken illegal drugs What Drug(s)_________________

Do you smoke?

How much____________ How Often__________Year Quit__________

Drink alcohol? How much____________ How often_________ Alcohol withdrawal?______________

Are you pregnant?

Are you taking Aspirin, Blood thinners or NSAIDS?

Date of last dose_____________________

Do you snore?

Have sleep apnea?

Use C-PAP?

Stop breathing during sleep?

Daytime tiredness?

History of sleep apnea or has anyone observed you stop breathing during sleep?

Are you allergic to: Medications

Foods

Soap

Tape

Latex

ALL

List

allergies

List Previous Surgery (ies)

Your anesthesiologist will talk and advise you regarding the type of anesthesia considered medically advisable. Modern day

anesthesia is very safe. However, you should understand that, like other medical procedures, the administration of anesthesia

is associated with certain risks. Major complications from anesthesia are extremely rare but they can result in death or disability.

Please sign below when you have completed this form to the best of your knowledge and are satisfied you understand its contents.

Signature ____________________________________________ Relationship_____________________

Patient Checklist, Medication List And Anesthesia Questionnaire Page 2

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