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					                            Anesthesia Preoperative Questionnaire



Name: ______________________________________________________________________________

Age: __________      Male Female (circle)            Height: __________ Weight: _________

Pre-Op Diagnosis (reason for surgery):
______________________________________________________________________________

Planned Surgery: ______________________________________________________________________________

Previous Surgeries: ______________________________________________________________________________

_____________________________________________________________________________

Any Problems with Anesthesia in the Past?                                        YES     NO

If YES, What? ______________________________________________________________________________

Have you ever been told you were “Difficult to Intubate” for Surgery? YES NO

Any Family History of SERIOUS Problem with Anesthesia? YES NO

(Malignant Hyperthermia, for example)



Current Medications: (Please Include Herbal Meds, Oxygen, and Inhalers)

______________________________                           _____________________________

______________________________                           _____________________________

______________________________                           _____________________________

______________________________                           _____________________________

Any Medications to which you are Allergic or have had significant side effects? (List
name of medicine and what the reaction was)
_________________________________________________________________________________________________________
___________________________________________________



Dental: (please circle)       Dentures                Removable Partial/Bridge Braces
                      Veneers

                                 Loose/Broken/ Teeth                  Abscessed/Infected Teeth



                  Please Circle Any Medical Problems You Have or Have Had:




                                                                                                        1
LUNGS:                                Heart Attack

      Asthma                          Bypass/Valve Surgery

      COPD/Emphysema                  Heart Stents/Angioplasty

      Chronic Bronchitis              Pacemaker or Defibrillator

      Obstructive Sleep Apnea         Heart Valve Problem

      CPAP or BiPAP                   Atrial Fibrillation

      Home Oxygen                     Palpitations

                                      Congested Heart Failure

Muscular/Skeletal:

      Muscular Dystrophy        GI:

      Chronic Neck Pain               Ulcers

      TMJ/Stiff Jaw                   Reflux

      Chronic Low Back Pain           Irritable Bowel

      Arthritis                       Colostomy



NEUROLOGIC:                     UROLOGIC:

      Down’s Syndrome                 Kidney Problems

      Depression                      Dialysis

      Drug Use or Dependency

      Alcoholism                ENDOCRINE:

      Schizophrenia                   Diabetes

      Stroke or TIA                   Thyroid

      Seizures




HEART:



                                                                   2

				
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