Surgical Clearance Questionnaire
Please answer all questions and provide explanations where necessary.
Patient:
*
Name
DOB
Have you ever had a heart attack?
*
Yes
No
If yes, when?
Have you ever experienced chest pain that was thought to be related to your heart?
*
Yes
No
If yes, when?
Have you ever been diagnosed with angina?
*
Yes
No
If yes, when?
Do you have any problems with your heart valves?
*
Yes
No
If yes, please describe:
Have you ever been diagnosed with an irregular heart beat?
*
Yes
No
If yes, when?
Do you have a pacemaker or defibrillator?
*
Yes
No
If yes, when was it placed?
Have you ever had an angioplasty or heart surgery?
*
Yes
No
If yes, when?
Do you take medication for high blood pressure?
*
Yes
No
If yes, please list name and dose:
Have you ever been diagnosed with congestive heart failure?
*
Yes
No
If yes, when?
Do your legs/feet swell?
*
Yes
No
If yes, please explain:
Do you become tired or short of breath when walking?
*
Yes
No
If yes, how far?
Are you able to climb 2 flights of stairs without stopping?
*
Yes
No
If no, please explain:
Have you ever been diagnosed with asthma or COPD?
*
Yes
No
If yes, when?
Have you ever been diagnosed with sleep apnea or have you been told that you stop breathing while you are asleep?
*
Yes
No
If yes, are you using a sleep apnea machine? Please explain:
Have you ever been diagnosed with a stroke or TIA?
*
Yes
No
If yes, when?
Have you ever had a seizure?
*
Yes
No
If yes, when?
Have you had one of the following?
*
muscular dystrophy
ALS (Lou Gehrig's Disease)
Multiple Sclerosis
Myasthenia Gravis
None of the above
Do you have diabetes?
*
Yes
No
If yes, how is it managed? i.e. Insulin, oral medication, diet, etc.
Have you ever been diagnosed with kidney problems or kidney failure?
*
Yes
No
If yes, when and how is it treated?
Do you bleed excessively when cut or bruise easily?
*
Yes
No
If yes, please expain:
Do you have a history of blood clots?
*
Yes
No
If yes, please explain:
Do you have a history of anemia?
*
Yes
No
If yes, please explain:
Do you have a history of problems with your thyroid gland?
*
Yes
No
If yes, please explain:
Do you have a history of hepatitis or liver problems?
*
Yes
No
If yes, please explain:
Have you been diagnosed with HIV/AIDS?
*
Yes
No
If yes, when?
Do you experience heart burn?
*
Yes
No
If so, how frequently?
Have you recently experienced blood in your urine or pain when urinating?
*
Yes
No
If yes, please explain and specify when:
Have you had any prior complications with anesthesia?
*
Yes
No
If yes, please explain:
Do you have a family history of anesthesia complications?
*
Yes
No
If yes, please explain:
Do you commonly experience any of these symptoms?
*
No
Yes
Immunology/Allergy: Seasonal allergies/hay fever, dermatitis, frequent itching, skin reactions, reactions to latex/rubber gloves, runny nose
General: Fever, fatigue, unexpected weight loss, weakness all over
Cardiovascular: Chest pain, heart palpitations, rapid heart beats, irregular
heart beats, high blood pressure
Integumentary: Changes in skin color, skin rashes, skin masses, skin
sores/ulcers, skin cancers
Endocrine: Frequent thirst, frequent hunger, hyperactivity, hypoactivity,
growth changes, hair changes
Ears/Nose/Throat: Decreased hearing, ringing in the ears, dizziness,
hoarseness, sinusitis
Hematology/Lymphatics: Bleeding tendency, easy bruising, lymph node
enlargement, anemia
Gastroenterology: Abdominal pain, nausea, stomach ulcers/reflux, heartburn, indigestion, appetite change, change in bowel habits,
diarrhea, constipation, loss of appetite
Musculoskeletal: Bone fractures, joint sprains, joint swelling, low back pain,
joint stiffness, osteoarthritis, rheumatoid arthritis, fibromyalgia
Neurological: Headaches, speech difficulty, stroke/TIA, numbness, tingling,
seizures, epilepsy, balance problems, falls
Eyes: Double vision, blurry vision, eye trauma, use of glasses/contacts
Psychiatric: Mood swings, sleep problems, depression, anxiety,
substance abuse, heavy alcohol use/drinking
Respiratory: Shortness of breath, asthma, bronchitis, chronic lung problems,
chronic cough
Genitourinary: Difficulty passing urine, incontinence, frequent urination,
urinary tract infections, painful menstruation/PMS
For any "yes" symptoms, please describe:
*
I hereby state that the above answers are complete and correct to the best of my knowledge.
Signature
*
Today's Date:
*
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Month
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Day
Year
Date
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