General Anesthesia Questionnaire (Please read and fill out the entire form) Gender Male Female Other Title Mr. Mrs. Ms. Miss Dr. Child/Youth Name * First Name Last Name Date of Birth * MM DD YYYY Age Weight * Please provide in kg / lbs. It is important to fill this section out. Note: If you weight over 250 lbs, please call us for clearance first. Height * Please provide in cm or ft/inches. Address * Home Phone (###) ### #### Business Phone (###) ### #### Cell Phone (###) ### #### Email Name of legal authority giving consent (if the patient cannot) * Note: this individual must be reachable at the time of anesthesia! If informed consent cannot be obtained, the surgery cannot proceed. First Name Last Name Phone number of legal authority giving consent * (###) ### #### Is any other applicable custodian (i.e. parent) informed and in agreement? * Yes No If No to above question, please explain below: Companion Information * First Name Last Name Phone number * (###) ### #### Relationship to patient: * Family Physician: * Family Physician Phone Number: * (###) ### #### Family Physician Address: * Patient's OHIP Number and Version Code: * Expiry * MM DD YYYY Does the patient have any health problems or concerns presently (including colds, flu, etc)? Please explain: * Please check all the conditions that apply to the patient: * High Blood Pressure Heart Disease Chest Pain, Angina, MI Heart Failure Shortness of Breath Pacemaker Irregular Heart Beat Abnormal Heart Valves Heart Murmur Liver Disease Hepatitis Daily Alcohol Drinking Alcohol Dependence Blood Clotting Disorder Anemia Thalassemia Kidney Disease Adrenal Gland Problems Diabetes, Thyroid HIV / AIDS Asthma Tuberculosis Cystic Fibrosis COPD / Bronchitis Emphysema Epilepsy / Seizures Fainting Spells Stroke / TIA Weakness / Paralysis Glaucoma Neuromuscular Condition Arthritis Artificial Joints Gastric Reflux / Heartburn Stomach Ulcers / Bleeding Developmental Delay Behavioral Issues No Medical Conditions Has there been ANY change in general health in the past year? * Has the patient ever been in hospital? When, where and why? * Has the patient ever had general anesthesia or surgery? When, where and why? * Were there any problems with the anesthesia? * Have the patient’s family relatives had problems during or after an anesthesia (i.e. malignant hyperthermia, pseudocholinesterase etc.)? Please explain. * Does the patient have a drug allergy? What drug? * What was the reaction to the drug? What happened? Check all that apply Rash Breathing Problems Swelling Other Does the patient have any other allergies? If yes, what type? * Does the patient take ANY medications currently (including puffers, birth-control pills)? Please list ALL medications including doses and times usually taken: * Does the patient use or take ANY non-prescription remedies (including herbal remedies) right now? If yes, what is the name? * Has the patient had a cortisone (steroid) type drug orally, injected or inhaled in the past year? When? For how long? * Has the patient taken any medicine for a long duration in the past that is not listed above? * If yes, please provide name and reason for use. Has the patient had aspirin or aspirin-containing compounds (ASA, Bufferin, Anacin, 222) within the last week? * Yes No Unsure Does the patient or does anyone in the family have a bleeding problem? * Yes No Unsure Has the patient ever had an excessive amount of bleeding following surgery such as tooth extraction? * Yes No Unsure Has the patient been exposed to any infectious diseases in the past month? If so, which? * Does the patient have any difficulty breathing while sleeping at home? Is the patient known to have ‘obstructive sleep apnea’? * Yes No Unsure Does the patient have any difficulty breathing through the nose? * Yes No Unsure Does the patient have nose bleeds? * If so, how many per week? Which side? Does the patient have problems walking (2 city blocks), running or climbing stairs (2 flights)? * Yes No Unsure Does the patient get short of breath easily? * Yes No Unsure Does the patient ever turn blue in colour and/or faint when trying to run or climb stairs? * Yes No Unsure Does the patient have any problems opening his/her mouth wide? * Yes No Does the patient have any problems moving his/her neck freely? * Yes No Unsure Has the patient ever had surgery and/or radiation treatment for a tumor or cancer? * Yes No Unsure Does the patient smoke? * If yes, how much? If the patient quit smoking, when was this (year and month)? Has the patient used recreational drugs (crack, cocaine or other drugs) in the last 6 months? * Yes No Unsure Is there any possibility that the (female) patient is pregnant? Yes No Unsure Is the (female) patient nursing? Yes No Does the patient have any loose teeth (especially front teeth) or capped teeth? * If so, where? Does the patient have ANY disease, condition or problem not mentioned so far? * Thrombosis Risk Factor Assessment: * Please check all pertinent factors Age 41 to 60 years Age 61 to 70 years Age over 70 years History of Deep Vein Thrombosis/PE Family history of Deep Vein Thrombosis Obesity (>20% of ideal body weight) Leg edema, ulcers, stasis Malignancy Pregnancy or postpartum (< 1 month) Inflammatory bowel disease Hormone therapy Nausea/Vomiting Risk Factor Assessment: * Please check all pertinent factors Female Nonsmoker History of :- postoperative nausea/vomiting (PONV) / Motion Sickness / Family history of PONV Obstructive Sleep Apnea Risk Factor Assessment: * Please check all pertinent factors You snore loudly (heard through closed doors You often feel tired, fatigued or sleepy during daytime Someone has observed you stop breathing during your sleep You have high blood pressure You are over 50 years old You are male I confirm that the above information is accurate to the best of my knowledge. * I confirm Date MM DD YYYY Relationship * Parent Gaurdian Patient Thank you!
