Pediatric Preop Anesthesia Questionnaire

Difficulty/concerns with previous anesthetic

Yes No
Please explain:
Blood relative (parent, sibling) who had a serious reaction to anesthesia that involved a fever, seizures or hospital admission

Yes No
Type of reaction:
Patient Medical History:
Congenital abnormality or developmental delay (such as Down’s syndrome, microcephaly, autism)

Yes No
If yes, explain:
Heart murmur or abnormal heart valve

Yes No
If yes, explain:
Asthma/bronchitis/sleep apnea

Yes No
If yes, explain:
Acid reflux

Yes No
If yes, explain:
Frequent bleeding/easy bruising

Yes No
If yes, explain:
Current cold or cough?

Yes No
Diabetes

Yes No
Is your child on an insulin pump?

Yes No
Average blood sugar/A1C
Other medical conditions
Allergies:
Yes No
Latex Iodine Shellfish Adhesives

Has your child been on steroids (oral, inhaled or intravenous) within the last 3 months?

Yes No
Please explain:
Parent/Guardian Contact Information:
Would you like the anesthesiologist to contact you by phone prior to the procedure?

Yes No
If so, please provide your name and phone number below:
Name
Contact number
Please enter a valid phone number.
The information I have provided above is accurate and complete regarding current and past illnesses, medications (including herbal supplements), and other matters pertaining to the patient's health and complete medical history.
Parent/Legal Guardian's Signature

Clear
Date

Month Day Year
Date
1002 15th STREET SW, SUITE 215, AUBURN, WASHINGTON 98001 PHONE (253)736-6600 FAX (253)288-2219
Should be Empty:

Patient Medical History: