Patient Health/Anesthesia Questionnaire

Type of Operation*
Surgeon*
Health Card Information
Health 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 Letters
Other Health Cards / Old OHIP Card
- Other Health Cards / Old OHIP Card
Health Number*
PATIENT INFORMATION
Hidden
Patient's Name*
as printed on Health Card
First Middle Last
Full Name*

as printed on Health Card
Preferred 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)*
Address
Street Address*
Address Line 2
City*
Province*
Postal 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):*

Do you have any Loose teeth, Caps, Crowns, Bridges, Dentures or other removable Dental Appliances?*
- No
- Yes
If yes, specify:*

Hidden
How 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:*

Have you taken Prednisone / Steroid medication in the last 6 months?*
- 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 Surgeries
Do you have any past surgeries?*
- No
- Yes
Past Surgeries*
Please list past surgeries and dates:
Surgery Name Surgery Date

MEDICATIONS
Are 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 mediations
DRUG 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
Email
This field is for validation purposes and should be left unchanged.

Health Card Information

Surgery Name	Surgery Date

DRUG NAME & DOSE