PRE-OPERATIVE ANESTHESIA QUESTIONNAIRE
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1 PRE-OPERATIVE ANESTHESIA QUESTIONNAIRE FOR THE PATIENTS UNDER 15 YEARS OF AGE (CHILDREN) An anesthesiologist is a doctor who anaesthetizes the patient (puts the patient to sleep). By using certain drugs the doctor causes transient suppression of the function of the central nervous system which is called general anesthesia=narcosis. General anesthesia is the most frequent choice in the case of children. During the procedure the anesthesiologist controls all the important vital functions such as: breathing, blood circulation, and awakes the patient after the procedure. ANESTHESIA About 30 minutes before the anesthesia the child is given sedative and sleeping syrup or a tablet. The child goes to the operating theater with a parent/carergiver to feel more comfortable. An intravenous access is usually used in the case of older, cooperative children. Younger children are usually anesthetized with the use of a face mask. Intravenous drug injection is better for children as falling asleep is faster and calmer. As soon as the child falls asleep, the parent/caregiver leaves the operation theater. At CM Krajmed we use slow awaking technique after the operation- this diminishes postoperative stress. After the procedure, the sleeping child is transferred to the postoperative room, where the patient is observed for approx. 30 minutes. After waking up, children usually feel well. They are seldom weepy, irritated or complaining about pain. The child informed about the planned surgery feels better and is calmer. You should ensure your child that they are not going to feel any pain or other unpleasant sensations. Parents often ask about anesthesia-related risks. The answer is that life or health threatening complications are extremely rare. They can be prevented by taking the following precautions: - Thorough patient s health assessment, - Analysis of additional test results, - Analysis of previous operations, - Analysis of diseases occurring in the immediate family, - Close cooperation between anesthesiologist and surgeon, - Use of safe (new generation) anesthetics; they are easy to control, safe, short-acting and they reduce adverse post-operative effects such as nausea, vomiting, long-time sleepiness after the operation - Selection of optimal anesthesia - Providing proper nursing care In order to have the most important information considering your health, we have prepared an anesthesia questionnaire. Please fill it in and bring to the consultation meeting with our anesthesiologist along with the medical documentation you have, such as your child s health certificate, test results, discharge summaries etc.
2 QUESTIONNAIRE- to be filled in by the patient Name and surname of the child:. Date of birth:..address: Telephone: Weight: Height:. Please circle the correct answer: (Y=YES, N=NO) 1. Is your child under specialist care due to a chronic disease Y N 2. Has your child been treated due to an infection in the last 3 weeks? Y N 3. Contagious disease during the last 12 months Measles Y N Chicken pox Y N Mumps Y N Mononucleosis Y N Diphteria Y N Scarlet fever Y N Other Y N 4. Vaccinations during the last 3 months Y N 5. Vaccination against viral hepatitis type B Y N 6. Currently taken drugs Y N 7. Hospitalization Y N 8. Previous operations/invasive diagnostic procedures? Y N 9. Complications during anesthesia? Y N 10. Complications during anesthesia in the family? Y N If you answered yes to any of questions 1-9, please describe: Does your child suffer from any of these diseases: 11. Circulatory system Abnormal heart rhythm Y N Congenital heart anomalies Y N Hypertension Y N 12. Respiratory system Pneumonia or bronchitis y N Lungs or bronchi hypersensitivity Y N
3 Asthma Y N Laryngitis Y N 13. Digestive system Motion sickness y N Esophageal reflux disease Y N Liver diseases Y N 14. Metabolic diseases Diabetes Y N Thyroid gland diseases Y N Porphyria Y N 15. Urinary tract Kidney inflammation Y N Bladder inflammation Y N 16. Skeletomuscular system Myasthenia Y N Myasthenia in the family Y N Difficulties in movement Y N Vertebral diseases Y N Hernias Y N 17. Oral cavity Abnormal dental occlusion Y N Cleft palate Y N Loose teeth Y N Crownwork Y N Removable orthodontic brace Y N Permanent orthodontic brace Y N 18. Nervous system Tremors Y N Epilepsy Y N Meningitis Y N Cerebral palsy Y N ADHD Y N Anorexia Y N Genetic disorders Y N Sight disorders Y N 19. Hematologic diseases or coagulation disorders Spontaneous bleeding Y N Prolonged bleeding after injuries Y N Tendency to bruising Y N
4 Prolonged wound healing Y N Hemophilia (also in the family) Y N Coagulation disorders in the family Y N Anemia Y N Blood transfusions Y N 20. Allergies Ingested allergens Y N Protein allergy Y N Soya Y N Inhaled allergens Y N Drugs Y N Contact allergens/ patches Y N If you answered yes to any of questions 11-20, please describe: Other important health issues: I DECLARE THAT I HAVE READ THIS QUESTIONNAIRE AND THAT ALL THE ANSWERS ARE TRUE. Date and parent s/caregiver s signature ANESTHESIA CONSENT FORM I had a meeting with an anesthesiologist who explained to me the anesthetic procedure before, during and after the operation. I understood the explanation and I asked all the questions I had regarding the anesthesia and possible complications. I have no further questions. I consent to conducting the following procedure. (the type of operation) in : -sedation - regional anesthesia
5 - general anesthesia I also agree to any medically justified additional procedures (second intravenous access, fluid infusion and blood transfusion), and, if necessary, to the change in the type of anesthesia. Parent /caregiver s signature. Warsaw, date My child s health has not changed significantly since the anesthesiologist consultation. Parent /caregiver s signature. Doctor s signature RECOMMENDATIONS: Meals: the child is not allowed to eat for 6 hours before the operation Drinks: the child is not allowed to drink for 4 hours before the operation, however, 2 hours before the operation it is recommended to drink 1/2 glass of still water in order to clean the stomach from acids Earrings, rings, chains, watches and the like should be left at home. Any removable braces or eye lenses should be taken out before the operation (in the Clinic) For 24 hours after the operation the child should be in an adult s care 2 weeks before the operation the child should not take drugs containing acetylsalicylic acid such as: Acard, Alka-Prim, Alka-Seltzer, Ascodan, Aspirin, Asprocol, Calcipiryna, Etopiryna, Polocard, Polopiryna, tablets against flu, Upsarin Declaration: I have followed the pre-operative recommendations for the child. Date and parent s/caregiver signature
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Name of Pa. tient: Last. First. per day) 50 mg. X-ray dye or. IV contract. Name (Last) (First) Address. City, state/ zip code
Division of Cardiology for the Academic Medical Center of the University of Texas Medical School at Houston NEW PATIENT HISTORY FORM Please complete and fax to 713-512-2245 Name of Pa tient: Last _ First
Who is filling out this intake form? Self Spouse Parent Guardian
Office Use Only: Reviewed with Patient Data Entry Scan & File Date: Date: Date: Initials: Initials: Initials: Today s Date: Who is filling out this intake form? Self Spouse Parent Guardian If you are not
Dr. Kelly Gillis ND BPHE (Lic. 3095) Doctor of Naturopathic Medicine
Dr. Kelly Gillis ND BPHE (Lic. 3095) Doctor of Naturopathic Medicine Naturopathic Pediatric Intake Form (Child 0-13 yrs) Child s name: Parent/Guardian s name(s): Address: Age: Date of Birth: DD/MM/YYYY
Children s of Alabama. Birmingham, Alabama
Preoperative Evaluation of Pediatric Patients Heather Rankin, CRNA, MSN Children s of Alabama Birmingham, Alabama Objectives Define NPO guidelines Review history assessment Review system assessment Review