Bring this entire packet with you, with the checklist completed, to your appointment.
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1 We are honored to have the opportunity to provide anesthesia services for your upcoming procedure. In order for us to provide safe anesthesia care, please review the instructions included. There are some forms that will need to be completed prior to your arrival. The checklist below indicates what needs to be completed. Bring this entire packet with you, with the checklist completed, to your appointment. Failure to complete this list may delay, and in some instances, cancel your procedure. Payment for anesthesia services is required prior to your procedure. If you have any questions about any of this material, please us at We will respond within 24 hours, so be sure to us early enough to receive a response. Our nurse will be available to answer additional questions when you check-in for your procedure. Checklist: Read the preoperative instructions, nothing to eat/drink after midnight, except what is explained. Take any medications as explained. Fill out the pre-anesthesia questionnaire, front and back. Read the anesthesia consent form. We will go over this with you and sign it the day of your procedure. Please bring a check or debit/credit card to pay your anesthesia fee. Payment is required before services are given. NO CASH PLEASE. If you do not know the anesthesia fee, please contact the office where the procedure will take place. They will have this information. Thank you in advance for your cooperation in completing this packet. We look forward to serving you. Sincerely, Aaron Ketcher, DNP, CRNA - President, Anesthesia Consultants of Arizona
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3 ANESTHESIA INSTRUCTIONS FOR YOUR PROCEDURE Please follow these instructions to help us provide the safest anesthesia possible for you or your family member. DAY BEFORE THE PROCEDURE - Make sure you have completed your packet checklist and remember to bring the packet with you. - Please refrain from eating or drinking at least 8 hours prior to your arrival time. o Pediatric Patients Only: Children may have small amounts (6 12 ounces total) of apple juice or other clear juices (no pulp or soda) up to 2 hours prior to their arrival time. It is perfectly safe for children to fast prior to anesthesia just like adults, they just might be a little more irritable. - Unless your dentist/surgeon has asked you to avoid certain medications, please take all your prescribed medications on their normal schedule, including narcotics or anti-anxiety medications. Take them with as little water as possible. o Diabetic Patients Only: Please do not take your regular insulin. You may take any of your oral medications. If you have an afternoon appointment, you may eat a liquid only breakfast at least 6 hours prior to your arrival time. - Wear a loose fitting top, as we will need to place various monitors on your chest and side, and have access to your arms for the placement of an IV catheter. MORNING OF PROCEDURE - Please brush your teeth thoroughly prior to your arrival, avoid swallowing anything. - Make sure to bring your completed anesthesia packet with you. - You must have a driver to take you to and from your appointment. You cannot drive for 24 hours following anesthesia. If you do not have someone to take you home, your procedure will be cancelled. If you fail to follow these instructions, your procedure may have to be postponed or cancelled. These guidelines are for your safety. AFTER YOUR PROCEDURE - You may be sleepy for the rest of the day. This is normal. Please make sure someone is with you for the next 24 hours. - You can return to a normal diet, or the diet that has been indicated by your dentist/surgeon. We recommend you start with lighter foods, so you don t become nauseated after anesthesia. Be sure to hydrate yourself well after the procedure. This will help alleviate any side effects you may experience. We look forward to the opportunity of taking care of you or your family member. We pride ourselves in excellent patient care and satisfaction. You will be receiving a phone call in the evening to follow-up on your anesthesia care and to see how you are doing. If you have any questions, please us at questions@acazgroup.com. We will respond within 24 hours. Thank you and we look forward to serving you.
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5 PRE- ANESTHESIA QUESTIONNAIRE Name: Date of Birth: Sex: M F Age: Date of Procedure: Office Name: Ht: Wt: Best Phone Number to Call: Primary Care Doctor, if any: Allergies to Medications, Supplements, or Foods: No Known Allergies Do you currently have or have you ever had: Cardiovascular: Yes No High Blood Pressure Peripheral vascular disease Atrial Fibrillation Heart Attack: when Chest pain/angina how often If yes, how treated Murmur /history of Rheumatic fever Pacemaker or Implanted defibrillator History of Congestive Heart Failure Respiratory: Asthma last ER visit COPD Sleep Apnea/CPAP/BIPAP Shortness of breath Can you walk one flight of stairs without stopping? Gastrointestinal: Hiatal Hernia Acid Reflex (GERD) Hepatitis Other GI/Liver problem- Musculoskeletal: Arthritis: Rheumatoid or Osteoarthritis Back or Neck pain Difficulty walking Hematologic: HIV+ Sickle cell disease or trait Bleeding/Easy bruising Blood thinners History of blood clots Genitourinary: Kidney Disease Dialysis: Hemo/peritoneal ( M T W TH F ) Neurological: Yes No Stroke or TIA when Paralysis where Parkinson s Disease Epilepsy last seizure Alzheimer s or Dementia Restless Leg Syndrome Other neurologic condition- Endocrine: Thyroid: Hyper or Hypo Diabetes (circle) Insulin pills diet controlled Females: Are you pregnant? Last menstrual period Tubal Ligation or Hysterectomy General: History of problems with Anesthesia If yes, what? Mastectomy: Left Right Do you smoke how long? Alcohol use how much/often? Recreational Drug use type and last use Pediatric Patients Only: Is there someone who smokes in the home? Currently sick? (Cold, Flu, Allergies) Taking antibiotics? Date started- Any family history of Malignant Hyperthermia? Any other problems not previously mentioned? Please fill out medication sheet and surgical history on the back of this page
6 MEDICATION AND SURGICAL HISTORY CURRENT MEDICATIONS Patient does not take any medications or supplements Please include: Prescriptions, OTC Medications, Nutritional Supplements, Vitamins, Herbs, Birth Control Pills, Patches, etc (Please do not use abbreviations) Medication Name Dose Route Frequency Please include another sheet of paper if necessary PAST SURGERIES Patient has never had surgery Please include all surgeries regardless of age/year they occurred Type of Surgery Approx. Date Problems if any?
7 CONSENT FOR ANESTHESIA SERVICES I,, acknowledge that my doctor has explained to me that I will have an operation or procedure performed, and has explained the risks associated with this procedure. I also understand that anesthesia services are needed so that my doctor can perform this procedure. It has been explained to me that all forms of anesthesia carry some risks and no guarantees or promises can be made concerning the result of my procedure. Although rare, unexpected severe complications with anesthesia can occur and include the remote possibility of infection, bleeding, drug reactions, loss of sensation, paralysis, stroke, brain damage, heart attack, or death. I understand these risks apply to all forms of anesthesia and that specific risks related to the type of anesthesia I will be receiving are explained further below. I will be receiving: Monitored Anesthesia Care (with moderate or deep sedation) Expected Result Technique Risks Reduced anxiety and pain, partial or total loss or memory, moderate to deep levels of sedation Drug injected into the bloodstream, either by intravenous access or intramuscular injection An unconscious state, depressed breathing, injury to blood vessels I hereby consent to the anesthesia service listed above and authorize that it be administered by the associates of Anesthesia Consultants of Arizona, LLC, all of whom are licensed and credentialed to provide anesthesia services in the state of Arizona and in this healthcare facility. I also consent to any alternative type of anesthesia, if necessary, as deemed appropriate by them. I certify and acknowledge that I have read this form or had it read to me; that I understand the risks and expected results of the anesthesia service; and that I had ample time to ask questions and to consider my decision. Patient s Signature or Authorized Rep. Date and Time Relationship to Patient Witness Signature, CRNA Anesthesia Provider s Signature A list of commonly used drugs for anesthesia is listed on the back of this form.
8 Propofol and Ketamine are short-acting hypnotic/sedatives. These drugs are administered to put you into a state of unconsciousness or sleep. The depth of this sleep varies based on the amount given by your anesthesia provider and the level required for you procedure. Some of the desired effects, and some rare side effects, are listed. Desired effects can include: Undesired effects can include: - Sedation - Drops in blood pressure or increases in blood pressure - Amnesia - Slowed breathing - Reduced anxiety - Changes in heart rhythm or arrhythmias - Pain relief - Seizures - Increased salivation - Headache Versed is a short acting drug given to reduce anxiety, cause amnesia, and put the patient in a relaxed state. Some of the desired effects, and some rare side effects, are listed. Desired effects can include: Undesired effects can include: - Drowsiness - Dizziness - Reduced anxiety - Nausea/Vomiting - Amnesia - Headache Fentanyl is a strong narcotic given to reduce or eliminate pain related to your procedure. Some of the desired effects, and some rare side effects, are listed. Desired effects can include: Undesired effects can include: - Drowsiness - Slowed breathing - Reduced pain - itching - Relaxation - Nausea/Vomiting
! Read the preoperative instructions, nothing to eat/drink after midnight, except what is explained. Take any medications as explained.
We are honored to have the opportunity to provide anesthesia services for your upcoming procedure. In order for us to provide safe anesthesia care, please review the instructions included. There are some
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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Last Name: First Name: Address: Apt/Unit #: City: State: Zip: Best Contact Phone Number: Date of Birth: Age: Profession:
Health Profile Our 30/10 program is intended to help participants with their personal weight loss efforts. We are not a medical facility, and our staff cannot give you medical or psychological advice.
PATIENT INFORMATION NAME: LAST FIRST MIDDLE ADDRESS: CITY: STATE: ZIP CODE DOB: / / AGE: MARITAL STATUS: M S D W SEP
PATIENT INFORMATION DATE: SS#: NAME: LAST FIRST MIDDLE ADDRESS: CITY: STATE: ZIP CODE DOB: / / AGE: MARITAL STATUS: M S D W SEP Primary contact #: ( ) Is this: Home Cell Work Other: May we leave a detailed
SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE
Patient Name MRN DATE: SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE Date of birth Age REASON FOR VISIT Abnormal Mammogram R L please specify Lump/Thickening R L upper lower inner outer Pain R L upper
medical questionnaire Date: Day Month Year
medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you
Thomas Kremen, MD ORTHOPAEDIC SURGERY AND SPORTS MEDICINE
Thomas Kremen, MD ORTHOPAEDIC SURGERY AND SPORTS MEDICINE New Knee Patient Intake Questionnaire PLEASE PRINT Please provide your referring physician s name, address (if known, if not list the city) and
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )
NAME (Please Print) First Name M.I. Last Name DATE of BIRTH / / - YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES ) Exam Date:,20 PRESCRIPTIONS DRUGS Please Print MEDICATIONS NAMES ONLY NO PRESCRIPTION
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name:
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine PATIENT DEMOGRAPHICS Who is the Physician that referred you to us? Who is the primary care Physician? Date: Do you want this report
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
FORM 3 PATIENT HEALTH QUESTIONNAIRE
FORM 3 PATIENT HEALTH QUESTIONNAIRE Return all forms to arrive at Gillies Hospital at least ONE WEEK before admission IMPORTANT: Please send this completed form to the hospital where you will have your
New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History
New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History Name PH#(home) Cell Address City Province Postal Code Date of Birth D/M/YY Age Gender Email address Do you exercise?
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
Huron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more