Preanesthesia Questionnaire

The preanesthesia questionnaire is used to help prepare you for your anesthetic and determine the best anesthetic technique for you. You will be specifically asked about your medical history, current medications, prior operations, and allergies. Additional questions may include:

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Yes No
❍   ❍ Have you recently had a cold, flu, or a fever?
❍   ❍ Are you allergic to latex (rubber) products?
❍   ❍ Have you experienced chest pain?
❍   ❍ Do you have a heart condition?
❍   ❍ Do you have hypertension (high blood pressure)?
❍   ❍ Do you experience shortness of breath?
❍   ❍ Do you have asthma, bronchitis, or any other breathing problem?
❍   ❍ Do you (or did you) smoke?
____________Number of years
____________Date you quit
❍   ❍ Do you consume alcohol?
❍   ❍ Do you take or have you taken recreational drugs?
❍   ❍ Have you taken cortisone (steroids) in the last six months?
❍   ❍ Do you take any non-steroidal, anti-inflammatory drugs?
❍   ❍ Do you have diabetes?
❍   ❍ Have you had hepatitis, liver disease, or jaundice?
❍   ❍ Do you have a thyroid condition?
❍   ❍ Do you have or have you had kidney disease?
❍   ❍ Do you have ulcers or other stomach disorders?
❍   ❍ Do you have a hiatal hernia?
❍   ❍ Do you have back or neck pain?
❍   ❍ Do you have numbness, weakness, or paralysis of your extremities?
❍   ❍ Do you have any muscle or nerve disease?
❍   ❍ Have you or any blood relatives had difficulties with anesthesia?
❍   ❍ Do you have bleeding problems or take anti-coagulation drugs (blood thinners)?
❍   ❍ Do you have loose, chipped, or false teeth? Bridgework? Oral piercings?
❍   ❍ Do you wear contact lenses?
❍   ❍ Have you ever received a blood transfusion?
❍   ❍ Have you ever been diagnosed with sleep apnea?
❍   ❍ (Women) Are you pregnant?