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361 Hospital Road, Suite 124 • Newport Beach, CA 92663 • (949) 631-0988 PRE-ANESTHESIA SURGERY QUESTIONNAIRE
1. Name of your regular family doctor _______________________________ Phone ___________ OR ❏ I do not have a regular family doctor 2. Have you ever had any problems with blood pressure, previous heart disease, palpitations or angina?____________________________________________ If yes, please explain: ___________________________________________________________________________________________________________ 3. Have you had an EKG in the past? If yes, where? when ___________________________________________________________________________________________________ 4. Have you had any ( Circle ) breathing problems, asthma, hay fever, chronic bronchitis, emphysema or shortness of breath? __________________________ 5. Have you had any ( Circle ) seizures, convulsions, migraine headaches, fainting spells or stroke? _________________________________________________ 6. Have you had ( Circle ) jaundice, hepatitis, liver disease or blood transfusion reactions? _______________________________________________________ 7. Do you have ( Circle ) diabetes, hypoglycemia or thyroid problems? _______________________________________________________________________ 8. Do you have kidney problems? ____________________________________________________________________________________________________ 9. Have you had ( Circle ) a cold, sore throat, or flu in the last two weeks? ____________________________________________________________________ 10. Any recent exposure to tuberculosis? ❏ Yes ❏ No Any of the following symptoms: night sweats, cough with bloody sputum? _______________________ 11. Within the last two weeks have you had any exposure to chicken pox, mumps, measles (rubeola), German measles (rubella)? ________________________ 12. Do you have any ( Circle ) physical disabilities, back pain, arthritis or bursitis? _______________________________________________________________ 13. Do you have sleep apnea? C-PAP? Sleeping disorders? Snoring?__________________________________________________________________________ 14. Any other medical conditions? List: __________________________________________________________________________________________________ 15. Do you have any implants? (Cardiac, Cosmetic, Orthopedic) List:____________________________________________________________________________ 16. Have you ever had motion sickness? ___________________________________________________________________________________________________ 17. Do you smoke? ______________________________ How much/day? ___________________________________________________________________ 18. Do you drink alcoholic beverages? _______________________ How much/week? __________________________________________________________ 19. Do you use recreational drugs? ___________ Please list_______________________________________________________________________________ 20. Do you have ( Circle ) any loose teeth, dentures, permanent or removable bridges or front capped teeth? _________________________________________ 21. Do you wear contacts? __________________________________________________________________________________________________________ 22. Do you have any difficulty opening your mouth? ______________________________________________________________________________________ 23. Have you or any blood relative had an unusual reaction to anesthesia or malignant hyperthermia? ______________________________________________ 24. Are you allergic to anything? List: __________________________________________________________________________________________________
25. Do you have a latex allergy? ______________________________________________________________________________________________________ 26. Within the last year have you had cortisone or steroids? ________________________________________________________________________________ 27. Within the last two weeks have you taken ( Circle ) a tranquilizer, diet pills or herbal medications? _______________________________________________ 28. Have you taken any medication today? List: __________________________________________________________________________________________ 29. Do you use aspirin, ibuprophen (Motrin), Advil, Aleve, Naproxen or Anaprox? _______________________________________________________________ Others ____________________________________________________________________Last date taken?_____________________________________ 30. Do you use blood thinners (Heparin, Lovenox, Coumadin, etc.)? ______________________________Last date taken?______________________________ 31. Do you have bleeding tendencies? _________________________________________________________________________________________________ 32. Could you be pregnant at this time? ___________________ Date of last menstrual period: ____________________________________________________ 33. Circle pain medications you have ever taken: ❑ Tylenol ❑ Percocet ❑ Codeine ❑ Aspirin ❑ Darvocet ❑ Vicodin ❑ Other ________________________ 34. Height: ______________________ Weight: ___________________________
(i.e. fever, nausea, vomiting, low blood pressure) COMPLETED BY: ___________________________________________________________________________________ RELATIONSHIP: ___________________________________________DATE: ___________________________________ REVIEWED BY: PRE-OP RN: _________________________________OR/GI R.N.:______________________________



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