Pre-Anesthetic Questionnaire
Patient name
First Name
Last Name
Age
Gender
Female
Male
Weight
Height
Do you have any allergy(s)?
Describe your allergy(s) in detail
Are you currently taking any prescription/over-the-counter medications, herbal, and/or dietary supplements?
Your current medications list
Describe all the surgeries you have had in the past
Respond to the following questions to help us determine and provide an anesthetic that is best for you
Rows
Yes
No
Have you recently had a cold or the flu?
1
2
Are you allergic to latex (rubber) products?
3
4
Have you experienced chest pain?
5
6
Do you have a heart condition?
7
8
Do you have hypertension (high blood pressure)?
9
10
Do you experience shortness of breath?
11
12
Do you have asthma, bronchitis, or any other breathing problem?
13
14
Do you/did you smoke?
15
16
Do you/did you consume alcohol?
17
18
Do you take, or have you taken, recreational drugs?
19
20
Have you taken cortisone (steroids) in the last six months?
21
22
Do you take any nonsteroidal, anti-inflammatory drugs (NSAIDs)?
23
24
Do you have diabetes?
25
26
Have you had hepatitis, liver disease, or jaundice?
27
28
Do you have a thyroid condition?
29
30
Do you have, or have you ever had, kidney disease?
31
32
Do you have ulcers or other stomach disorders?
33
34
Do you have a hiatal hernia?
35
36
Do you have back or neck pain?
37
38
Do you have numbness, weakness, or paralysis of your extremities?
39
40
Do you have any muscle or nerve disease?
41
42
Do you, or any of your family, have sickle cell trait?
43
44
Have you, or any blood relatives, had difficulties with anesthesia?
45
46
Do you have bleeding problems?
47
48
Do you have loose, chipped, or false teeth? Bridgework? Oral piercings (such as
studs or rings) in your tongue or lip?
49
50
Do you wear contact lenses?
51
52
Have you ever received a blood transfusion?
53
54
Are you pregnant? (for women)
55
56
Have you had any anesthesia before?
57
58
Are there any specific things you would like your anesthesiologist to know?
Submit
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