Anesthesia Preoperative Patient History
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- Dinah Wilcox
- 6 years ago
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1 Anesthesia Preoperative Patient History Please Complete and BRING WITH YOU to Your Anesthesia Appointment Patient Name: Date of Birth: Phone Number: Kind of Surgery You are Having: Date of Your Surgery: (if known) Name of Doctor Doing the Surgery: Name of Your Primary Care Doctor: List all surgeries or procedures you have had and the dates of when you had them. Surgery or Procedure Date List any allergies you have to medications, latex, food and any other allergies. Also list your reactions to them. Page 1 of 6
2 Check off any TESTS that you have already had. Give the location of where you had the test done and the date you had the test. Bring all test results and reports to your appointment. You may not need these tests. DO NOT get these tests just because you may be having surgery. If you already had these tests done bring them to your appointment. ECG Name of Test Location of Test Date Sleep Study Blood Work Stress Test Echo (Ultrasound Of Heart) Pulmonary Function Test (Breathing Test) List any other tests you have had. Give the location of where you had the tests done and the date of the test. Name of Test Location of Test Date List all medications you have taken in the last month. Include over-the-counter drugs, inhalers, herbals, dietary supplements and aspirin or you can bring all of your medication bottles. The Dose: How much you take and Name of Medication or Other Drugs how many times a day you take it Page 2 of 6
3 Have you or anyone in your family had serious problems with: (Check all that apply) se Bleeds Bleeding with Tooth Extractions Bleeding After Surgery Have you ever had problems with anesthesia or surgery? (Check all that apply) Severe Nausea or Vomiting Malignant Hyperthermia (in family who are blood relatives or in yourself) Breathing Difficulties Problems With Placement of a Breathing Tube Do you have any of the following? Chipped or Loose Teeth, Dentures, Partials Problems Moving Your Neck Problems Opening Your Mouth Women: Could you be pregnant? Women: When did your last menstrual period begin? Date: Have you had any of the following problems with your heart or blood vessels? (Check all that apply) Heart Failure (fluid in your lungs) Murmur or Heart Valve Problem Heart or Blood Vessel Surgery Heart Attack or Heart Stents Chest Pain or Pressure Blockage of Arteries Palpitations/Irregular Heart Beat Implanted Device (ICD, pacemaker) Are you on a blood thinner? Examples: Aspirin, Coumadin (warfarin), Plavix (clopidogrel), Effient (prasugrel), Pradaxa (dibigatran), Xeralto (rivaroxaban), Eliquis (apixaban) Can you walk up one flight of stairs without stopping? Are you limited in the things you can do during the day because of your physical ability? Do you have diabetes? Page 3 of 6
4 Have you had any of the following problems with your lungs or your chest? (Check all that apply) Shortness of Breath COPD or Emphysema High Blood Pressure in the Lungs (pulmonary hypertension) Cystic fibrosis Asthma Pulmonary Fibrosis TB (tuberculosis) Sarcoidosis Have you taken steroids (prednisone or cortisone) in the last year? Do you use oxygen at home during the day or night? Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Do you often feel tired, fatigued, or sleepy during the daytime? Has anyone observed you stop breathing during your sleep? Do you have or are you being treated for high blood pressure? Do you have sleep apnea? Have you ever smoked? What was the date you quit smoking? How many packs a day did you smoke? How many years did you smoke? Do you still smoke? How many packs a day do you smoke? Do you drink alcohol? Date: Number of Packs: Number of Years: Number of Packs: How much do you drink in an average week? Number of drinks: Have you ever had alcohol withdrawal symptoms or seizures? Do you use or have you ever used any street (illicit) drugs, marijuana or opioids not prescribed for you? If yes, please list type of drugs Page 4 of 6
5 Have you ever been treated with chemotherapy or radiation therapy? If yes, list treatment and date of last treatment. Name of Treatment Last Treatment Date Have you had any of these problems with your blood? (Check all that apply) Leukemia or Lymphoma Hemophilia Blood Clots Anemia Sickle Cell Disease Blood Transfusion in the past Have you had problems with your (Check all that apply) Liver Cirrhosis Hepatitis A, B, or C Jaundice Kidneys Kidney Stones Kidney Failure or Dialysis Digestive System Frequent Heartburn Hiatal Hernia Ulcers Back, Neck or Jaw TMJ Rheumatoid Arthritis Herniated Disk or Back Problems Thyroid Problems Page 5 of 6
6 Nerves or Muscles Seizures TIA or Stroke Facial, Leg or Arm Weakness Neurologic Disorder, Examples: Multiple Sclerosis, ALS, Alzheimer s Muscular Disorder, Examples: Myasthenia Gravis, Muscular Dystrophy Problems With Hearing, Vision or Memory Severe Anxiety or Depression Chronic Pain Do you have Glaucoma? Please list any additional medical illnesses you have that were not noted above. Do you have any comments or questions for the anesthesiologist? Please write any questions or comments you have: Page 6 of 6
3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication
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WASHINGTON UNIVERSITY SCHOOL OF MEDICINE Cranial Health History Form Welcome to the Neurosurgery Department at Washington University. To help us treat you, please fill this form out completely. Your Name:
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
Name: Age: Date: Accompanied by Relationship E-mail: @ MEDICAL BACKGROUND INFORMATION Please name the professionals that you have seen for this condition: Name Specialty Town Phone Who is your primary
Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13