Patient Health/Anesthesia Questionnaire

Type of Operation*

Surgeon*

OHIP*

OHIP Version*

One / Two Right Side Letters

Other Health Cards / Old OHIP Card

Other Health Cards / Old OHIP Card

Health Number*

PATIENT INFORMATION

Patient Name*

Date of Birth*

Age*

Gender*

Female
Male
Gender Neutral

Phone Number (you can be reached)*

Email*

Occupation*

Marital Status*

Children

Height*

cm
ft/in

Height (cm)*

Height (ft/in)*

Weight*

kg
lbs

Weight (kg)*

Weight (lbs)*

Family Physician

Family Physician phone #

Address

Street Address*

Address Line 2

City*

Province*

Postal Code*

Do you have any ALLERGIES?*

No
Yes

If yes, please list and include the effect/reaction (medication, latex, food & other):*

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:*

Are you pregnant or do you think you could be pregnant?

No
Yes

Date of Last menstrual Period*

Do you have any Loose teeth, Caps, Crowns, Bridges, Dentures or other removable Dental Appliances?*

No
Yes

If yes, specify:*

Smoking

Have 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:*

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:*

Do you have, or have you ever had

PLEASE 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*

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

Comments

This field is for validation purposes and should be left unchanged.