Patient Health/Anesthesia Questionnaire Step 1 of 15 6% Type of Operation* Surgeon* Health Card InformationHealth Card Number is required for OHIP covered services, such as submitting COVID-19 Test Results, Blood Tests, ECG Monitoring, Anesthesia Consults and Pathology.OHIP* OHIP Version* One / Two Right Side LettersOther Health Cards / Old OHIP Card Other Health Cards / Old OHIP Card Health Number* PATIENT INFORMATIONHiddenPatient's Name*as printed on Health Card First Middle Last Full Name* as printed on Health CardPreferred Name Date of Birth* YYYY slash MM slash DD Age* Gender* Female Male Gender Neutral Marital Status* Married Divorced Single Widowed Phone Number (you can be reached)*Email* Occupation* Children # Height* cm ft/in Height (cm)* Height (ft/in)* Weight* kg lbs Weight (kg)* Weight (lbs)* AddressStreet Address* Address Line 2 City* Province*OntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutPrince Edward IslandQuebecSaskatchewanYukonPostal Code* Family Physician Family Physician phone # Your COVID-19 Vaccination Status:* Got 2 Doses Got 1 Dose Not Vaccinated Do you have any ALLERGIES?* No Yes If yes, please list and include the effect/reaction (medication, latex, food & other):* Are you pregnant or do you think you could be pregnant? No Yes Date of Last menstrual Period* YYYY slash MM slash DD Do you have any Loose teeth, Caps, Crowns, Bridges, Dentures or other removable Dental Appliances?* No Yes If yes, specify:* SmokingHave you ever Smoke?* No Yes Current smoking situation:* Quit Smoker How many cigarettes do you smoke in a day?* Smoker for how many years?* How many years ago you quit smoking?* Any cough?* No Yes Type of Cough:* Dry Wet Do you take, or have you ever taken any ADDICTING DRUGS?* No Yes Please list:* HiddenHow much alcohol do you drink in a week?*glass(es) How much alcohol do you drink in a week?*glass(es)Please enter a number from 0 to 99.What type of alcohol:* Do you have, or have you ever hadPLEASE DOCUMENT COMMENTS & DATES OF OCCURRENCES for each of the following questions asked:Angina or chest pain* No Yes Chest pain climbing one flight of stairs or / at night* No Yes Heart attack / Heart Failure* No Yes High blood pressure* No Yes Palpitations / Irregular pulse / Heart murmur* No Yes Pacemaker / Internal Defibrillator (ICD)* No Yes Bypass surgery /Angioplasty / Stent* No Yes Valve replacement / Heart transplant* No Yes Stroke / TIA* No Yes Peripheral Vascular Disease e.g. DVT, phlebitis, blood clot, aortic aneurysm, arterial or carotid bypass surgery* No Yes Aspirin, Coumadin, Plavix, other Blood Thinners* No Yes Asthma* No Yes Chronic bronchitis / emphysema / COPD* No Yes Sleep apnea (heavy snoring, choking, use of CPAP)* No Yes Shortness of breath climbing one flight of stairs or/at night* No Yes Tuberculosis* No Yes Any other lung problems* No Yes Diabetes* No Yes Liver Disease / Hepatitis* No Yes Sickle Cell Disease/Trait/or Family History of Anemia* No Yes Easy bleeding or bruising* No Yes Thyroid Problems* No Yes Muscular Dystrophy, Epilepsy/Seizure, Polio* No Yes Kidney problems* No Yes Acid reflux or frequent heartburn / Ulcer / Hiatus Hernia* No Yes Rheumatoid arthritis / Aankylosing spondylitis* No Yes Chronic Neck / Back / Muscle Injury or Problems* No Yes Fibroids or Heavy bleeding during menstrual cycle (Female Only)* No Yes Have you taken Prednisone / Steroid medication in the last 6 months?* No Yes When?* Have you ever had a blood transfusion?* No Yes When?* Do you or have you ever had any serious illness (Cancer, Chemotherapy etc) not mentioned?* No Yes Please explain* Have you ever had Anesthetic?* No Yes Types of Anesthetics you had:* General (“asleep for surgery”) Epidural Spinal Local Have you or a relative had any reactions/problems with past anesthetics?*E.g. Malignant Hyperthermia, Pseudocholinesterase Deficiency, Anaphylactic Reaction. No Yes If yes, specify:* Past SurgeriesDo you have any past surgeries?* No Yes Past Surgeries*Please list past surgeries and dates:Surgery NameSurgery Date MEDICATIONSAre you taking any medications*including over-the-counter drugs, puffers, insulin: No Yes List all MEDICATIONS*including over-the-counter drugs, puffers, insulin List all herbal/naturopathic mediationsDRUG NAME & DOSE Consent* By initiating this form, I confirm that my answers are true and have been answered to the best of my ability. Initiate*Patient Date*Initiate YYYY slash MM slash DD PhoneThis field is for validation purposes and should be left unchanged.
