Pre-Anaesthesia Questionnaire (Adult)

1.Do you have any health problems or concerns presently?

Yes
No
Not sure

2. Has there been ANY change in your general health in the past year?

When did you last have a complete physical exam?

How often do you see your family doctor or specialist?

Yes
No
Not sure

3. Have you ever been in hospital for treatment?

When, where and why?

Yes
No
Not sure

4. Have you ever had general anaesthesia or surgery?

Yes
No
Not sure

5. Have you or any of your family relatives had problems with anaesthesia?

Yes
No
Not sure

6. Do you have a drug allergy?

Yes
No
Not sure

7. Do you have any other allergies (e.g. latex)?

Yes
No
Not sure

8. Do you take ANY prescription medications (including puffers and birth control pills)? If yes provide Pharmacy name + number

+
Yes
No
Not sure

9. Do you use or take ANY non-prescription remedies (including herbal remedies)?

+
Yes
No
Not sure

10. Have you taken a cortisone (steroid) type drug orally in the past year?

Yes
No
Not sure

11. Do you or any of your relatives have a bleeding problem?

Yes
No
Not sure

12. Do you have or have had any difficulty breathing through your nose?

Yes
No
Not sure

13. Do you have any nose bleeds?

Yes
No
Not sure

14. Do you have or have had any difficulty breathing while sleeping at home?

Yes
No
Not sure

15. Can you walk up 2 flights of stairs or 2 city blocks quickly without resting?

Yes
No
Not sure

16. Do you have or have you ever had any of the following?

No to all

   

Heart murmur

Yes
No
Not sure

Heart attack

Yes
No
Not sure

Chest pain or angina

Yes
No
Not sure

Shortness of breath lying down

Yes
No
Not sure

Swollen ankles

Yes
No
Not sure

Heart pacemaker/defibrillator

Yes
No
Not sure

Irregular heart beat/arrhythmia

Yes
No
Not sure

High blood pressure

Yes
No
Not sure

Congenital heart disease

Yes
No
Not sure

Damaged/abnormal heart valves

Yes
No
Not sure

Rheumatic fever

Yes
No
Not sure

Kidney disease

Yes
No
Not sure

HIV, AIDS or STD

Yes
No
Not sure

Malignant hyperthermia

Yes
No
Not sure

Pseudocholinesterase deficiency

Yes
No
Not sure

Cancer / Chemotherapy

Yes
No
Not sure

Sleep apnea

Yes
No
Not sure

Asthma

Yes
No
Not sure

Emphysema / Bronchitis

Yes
No
Not sure

Cystic fibrosis / Tuberculosis

Yes
No
Not sure

Epilepsy

Yes
No
Not sure

Stroke

Yes
No
Not sure

Fainting spells, dizziness

Yes
No
Not sure

Diabetes

Yes
No
Not sure

Thyroid problems

Yes
No
Not sure

Adrenal gland problems

Yes
No
Not sure

Hepatitis

Yes
No
Not sure

Liver disease / Jaundice

Yes
No
Not sure

Anemia (including sickle cell)

Yes
No
Not sure

Blood disorders/transfusions

Yes
No
Not sure

Bleeding (Coagulation) disorders

Yes
No
Not sure

Stomach ulcers/ Acid Reflux

Yes
No
Not sure

Bone, joint, or muscle problems

Yes
No
Not sure

Artificial joints - hips, knees

Yes
No
Not sure

Arthritis

Yes
No
Not sure

Depression / anxiety

Yes
No
Not sure

Vision problems / glaucoma

Yes
No
Not sure

Mentally disabled

Yes
No
Not sure

Cerebral palsy

Yes
No
Not sure

Autism or Down’s syndrome

Yes
No
Not sure

WOMEN:

Are you pregnant?

Yes
No
Not sure

Are you a nursing mother?

Yes
No
Not sure

Any problems with menstruation?

Yes
No
Not sure

17. Do you ever have episodes of blurred vision or black spots, or experience weakness or paralysis on one side of your body, arms, legs or face?

Yes
No
Not sure

18. Do you have any problems opening your mouth wide or moving your neck fully?

Yes
No
Not sure

19. Have you ever had surgery, radiation or chemotherapy treatment for a tumour or cancer?

Yes
No
Not sure

20. Do you smoke?

Yes
No
Not sure

21. Do you drink more than 5 alcoholic beverages per week?

Yes
No
Not sure

22. Do you have a history of alcoholism or drug dependence?

Yes
No
Not sure

23. Have you taken any “recreational” drugs in the past year such as marijuana, LSD, PCP, cocaine, crack, "crystal meth", codeine, oxycodone or other drugs?

Yes
No
Not sure

24. Do you have ANY disease, condition or problem not listed above?

Yes
No
Not sure

25. How much do you weigh?

What`s your height?

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