Patient Health/Anesthesia Questionnaire Type of Operation*Surgeon*Health Number*Health Number Version*One / Two Right Side LettersPATIENT INFORMATIONPatient Name*Date of Birth* Date Format: YYYY slash MM slash DD Age*Gender*FemaleMaleGender NeutralPhone Number (you can be reached)*Email* Occupation*Marital Status*MarriedDivorcedSingleWidowedChildrenHeight*cmft/inHeight (cm)*Height (ft/in)*Weight*kglbsWeight (kg)*Weight (lbs)*Family PhysicianFamily Physician phone #Do you have any ALLERGIES?*NoYesIf yes, please list and include the effect/reaction (medication, latex, food & other):*Have you ever had Anesthetic?*NoYesTypes 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.NoYesIf yes, specify:*Are you pregnant or do you think you could be pregnant?NoYesDate of Last menstrual Period* Date Format: YYYY slash MM slash DD Do you have any Loose teeth, Caps, Crowns, Bridges, Dentures or other removable Dental Appliances?*NoYesIf yes, specify:*SmokingHave you ever Smoke?*NoYesCurrent smoking situation:*QuitSmokerHow many cigarettes do you smoke in a day?*Smoker for how many years?*How many years ago you quit smoking?*Any cough?*NoYesType of Cough:* Dry Wet Do you take, or have you ever taken any ADDICTING DRUGS?*NoYesPlease list:*How much alcohol do you drink in a week?*glass(es)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*NoYesChest pain climbing one flight of stairs or / at night*NoYesHeart attack / Heart Failure*NoYesHigh blood pressure*NoYesPalpitations / Irregular pulse / Heart murmur*NoYesPacemaker / Internal Defibrillator (ICD)*NoYesBypass surgery /Angioplasty / Stent*NoYesValve replacement / Heart transplant*NoYesStroke / TIA*NoYesPeripheral Vascular Disease e.g. DVT, phlebitis, blood clot, aortic aneurysm, arterial or carotid bypass surgery*NoYesAspirin, Coumadin, Plavix, other Blood Thinners*NoYesAsthma*NoYesChronic bronchitis / emphysema / COPD*NoYesSleep apnea (heavy snoring, choking, use of CPAP)*NoYesShortness of breath climbing one flight of stairs or/at night*NoYesTuberculosis*NoYesAny other lung problems*NoYesDiabetes*NoYesLiver Disease / Hepatitis*NoYesSickle Cell Disease/Trait/or Family History of Anemia*NoYesEasy bleeding or bruising*NoYesThyroid Problems*NoYesMuscular Dystrophy, Epilepsy/Seizure, Polio*NoYesKidney problems*NoYesAcid reflux or frequent heartburn / Ulcer / Hiatus Hernia*NoYesRheumatoid arthritis / Aankylosing spondylitis*NoYesChronic Neck / Back / Muscle Injury or Problems*NoYesHave you taken Prednisone / Steroid medication in the last 6 months?*NoYesWhen?*Have you ever had a blood transfusion?*NoYesWhen?*Do you or have you ever had any serious illness (Cancer, Chemotherapy etc) not mentioned?*NoYesPlease explain*Past SurgeriesDo you have any past surgeries?*NoYesPast Surgeries*Please list past surgeries and dates:Surgery NameSurgery Date MEDICATIONSAre you taking any medications*including over-the-counter drugs, puffers, insulin:NoYesList 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*PatientDate*Initiate Date Format: YYYY slash MM slash DD Let’s Talk Book Your Consultation Today at 416-360-7-360! Book Appointment
