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Microsoft word - pre-anesthetic questionnaire.doc
Pre-Anesthetic Questionnaire: DATE:__________________ 1 of 4
“CHIEF COMPLAINT”:________________________________________________ PROPOSED OPERATION:_________________________________________________HT:_____WT:______ CELL PHONE #:_______________NO ___ YES___ DISCLOSURE ALERT Primary Care Physician: PLEASE LIST ALL PREVIOUS OPERATIONS OR PROCEDURE /DATE:
1_______________________________/_______ 5 _______________________________/_______
______________________ 2_______________________________/_______ 6 _______________________________/_______
Cardiologist:( Date of last visit) 3_______________________________/_______ 7 _______________________________/_______
4_______________________________/_______
8 _______________________________/_______
Approximate date of last Anesthetic/Surgery__________________
Have you had any problems with anesthesia?
NO_______ YES_______ _______________________________
Have you been told you are difficult to intubate (insert breathing tube)? NO_______ YES_______ _____________________________ Have any blood relatives had a serious problem with anesthesia? NO_______ YES_______ ______________________________ Have you taken steroids (Cortisone, Prednisone,
Hydrocortisone, or Decadron )within the past 12 months? NO_______ YES_______ ______________________________
REVIEW OF SYSTEMS: DO YOU HAVE A HISTORY OF THE FOLLOWING MEDICAL PROBLEMS?
_____ _____ Any Heart Studies (EKG, Stress Tests, Angiogram)
_____ _____ Chest Pain, Shortness of Breath
If yes, Fasting Blood Sugar ________________Range
______ _____ Anemia, Easy Bruising, Free Bleeding
_____ _____ Heart Murmur/Irregular Heartbeat
______ _____ Sickle Cell, Other Blood Disease
_____ _____ Elevated Cholesterol, Triglycerides
_____ _____ Varicose Veins, Vascular Disorders
______ _____ Stroke, Paralysis, Other Neuro Disorder
_____ _____ Prev. DVT (blood clot in legs or lungs) ______ _____ Depression, Anxiety, Psych Disorder _____ _____ Asthma, Bronchitis, Emphysema, Other Lung Disease ______ _____ Back Problems, Arthritis, Swelling _____ _____ Limited Neck Motion, Pain, or Injury
_____ _____ Jaw Clicking, Pain or Stiffness
_____ _____ Ulcerative Colitis, Crohn’s Disease, IBS _______ _____ History of Multi Drug Resistant Organism _____ _____ Previous colonoscopy, hx colon polyps (MRSA, VRE, etc.) _____ _____ Family history colon cancer ______ _____ Headaches or Recent Visual Changes
_____ _____ Nausea, Vomiting (Persistent)
______ _____ Cancer, Immunosuppression, Chemotherapy
Indigestion, Ulcers, Reflux, Hiatal Hernia
______ _____ Breathing difficulties when lying flat
_____ _____ Facial Plastic or Reconstructive Surgery
______ _____ Sleep Apnea. If yes, CPAP machine used?__
______ _____ Family History of Heart Disease Other:____________________________________________________________________________________________________
Do you frequently awaken with numbness in an arm or leg? NO_____ YES_____
Are you Pregnant? NO_____ YES_____ Not Sure_____ Not Applicable_____ Date of last menstrual period________________
Are you Right handed?_____ Left handed?______
Do you wear contact lenses? NO_____ YES_____ NOTE: If yes, please remove them before surgery.
Do you have Capped Teeth / Crowns__________ Loose Teeth___________ Bridges___________ Dentures/Partials_____________
Do you have Advance Directives/ Living Will? NO _________ YES _________ (If YES, please have patient bring copy, if possible)
SOCIAL HISTORY
Occupation:_______________________________ What type of exercise do you get?__________________________________________
Do/Did you smoke? NO_____ YES_____ Packs Per Day______ How many Years?___________ Quit when?____________________
What is your alcohol consumption?_________________________________________________________________________________
Do/Did you have a problem with drug or alcohol dependence/addiction?____________________________________________________
Do you have a religious objection to blood transfusion? NO_____ YES_____
PATIENT SIGNATURE
____________ VERIFIED BY:_________________________RN TIME:__________
Prof. Dr. med. Michael H. R. Eichbaum Curriculum vitae Personalien Name: verheiratet mit Dr. med. Christine Eichbaum, geb. Loebel; eine Tochter (Katharina), einen Sohn (Julius) Schulischer Werdegang: Grundschule Universitärer Werdegang: Studium der Humanmedizin Ruprecht-Karls-Universität Heidelberg, Université de Paris VI III. Medizinisches Staatsexamen („gut“