6 HIGHLAND STREET • WEST WARWICK, R. I. 02893 • 401-826-8720 • 800-521-APRO • Fax 401-826-8722

Pre-Anesthetic Questionnaire

Please answer the following questions. Your responses will help us provide the anesthetic that is best for you.

YES NO

Have you recently had a cold or the flu?

Are you allergic to latex (rubber) products?

Have you experienced chest pain?

Do you have a heart condition?

Do you have hypertension (high blood pressure)?

Do you have asthma, bronchitis, or any other breathing problem?

Do you (or did you) smoke?
Packs/day . Number of years . Date you quit .

Do you consume alcohol?
Drinks/week .

Do you (or have you taken) recreational drugs?

Have you taken cortisone (steroids) in the last six months?

Do you have diabetes?

Have you had hepetitis, liver desease, or jaundice?

Do you have a thyroid condition?

Do you have ulcers or other stomach disorders?

Do you have a hiatal hernia?

Do you have back or neck pain?

Do you have numbness, weakness, or paralysis of your extremities?

Do you have any muscle or nerve disease?

Do you or any of your family have the sickle cell trait?

Have you or any blood relatives had difficulties with anesthesia?

Do you have loose, chipped, false teeth, or bridegwork?

Do you wear contact lenses?

Have you ever received a blood transfusion?

Are you pregnant? Due date.

Note that this form is provided for your reference only. Nothing that you enter is recorded or saved in any way. You may print this form to use with your nurse anesthetist if you wish.

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YES	NO
		Have you recently had a cold or the flu?
		Are you allergic to latex (rubber) products?
		Have you experienced chest pain?
		Do you have a heart condition?
		Do you have hypertension (high blood pressure)?
		Do you have asthma, bronchitis, or any other breathing problem?
		Do you (or did you) smoke? Packs/day . Number of years . Date you quit .
		Do you consume alcohol? Drinks/week .
		Do you (or have you taken) recreational drugs?
		Have you taken cortisone (steroids) in the last six months?
		Do you have diabetes?
		Have you had hepetitis, liver desease, or jaundice?
		Do you have a thyroid condition?
		Do you have ulcers or other stomach disorders?
		Do you have a hiatal hernia?
		Do you have back or neck pain?
		Do you have numbness, weakness, or paralysis of your extremities?
		Do you have any muscle or nerve disease?
		Do you or any of your family have the sickle cell trait?
		Have you or any blood relatives had difficulties with anesthesia?
		Do you have loose, chipped, false teeth, or bridegwork?
		Do you wear contact lenses?
		Have you ever received a blood transfusion?
		Are you pregnant? Due date.