New Patient Preoperative Questionnaire
Please review and answer these questions regarding your medical history. Understand that this information must be as complete as possible to ensure that you are receiving the proper anesthetic care for your individual needs.
Patient Name
*
First Name
Last Name
Primary Care Physician
*
Specialists
*
If none, list "none"
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Date of Birth
*
-
Month
-
Day
Year
Date
Age
Height
*
Weight
*
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Cell Phone Number
Please enter a valid phone number.
Home Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Daily medications
Including all of the following: Prescriptions, Pain patches, Over-the-counter, Inhalers, Vitamin/Herbal, and Dietary Supplements.
Click below to skip this section (daily medications)
I do not take any medications daily
I only take over-the-counter medicine such as vitamins
List all medications. Use the plus sign to add a new medication to the form.
Allergies
List all allergies to Medications, Foods, and Other Substances such as Latex, Rubber, Shellfish, Iodine, Tape.
List all allergies.
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Tobacco, Alcohol, Illicit drugs
Check all that apply
Alcohol Consumption
Daily
Weekly
Monthly
Never
Have you ever used tobacco/nicotine?
*
Cigarette smoking
E-cigs/Vaping
I am a non-smoker
Date stopped (if applicable)
Check each box that applies if you have used these additional substances:
Marijuana/CBD/Gummies
Cocaine/Crack
Methamphetamines
Heroine
Other
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Anesthetic History
Click here to skip this section (anesthetic history)
I have never had anesthesia previously
Previous operations/procedures that required anesthesia?
List all surgical implants:
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Cardiac History
Click here to skip this section (cardiac history)
I do not have any heart health issues
Check all heart conditions that apply
Abnormal EKG
High blood pressure
High cholesterol
Heart disease/coronary heart disease
Heart murmur/heart valve
Congestive heart failure/swelling of feet/ankles
Peripheral vascular disease
Cardiac Stents
Pacemaker
Defibrillator
Irregular heartbeat
Palpitations
Atrial Fibrillation
Other
Are you able to go up 2 flights of stairs or walk 2 blocks without chest pain or shortness of breath?
Yes
No
Angina/ chest pain
While at rest
During physical activity
Heart Attack: Year
If applicable
Open heart surgery: Year
Catherization: Year
Stress test: Year
Last cardiologist visit: Month/Year
Cardiologist Name:
Aneurysm or vena cava surgical clips?
Yes
No
Other Information
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Renal & Endocrine History
Click here to skip this section (renal & endocrine history)
I do not have thyroid, kidney, or blood sugar problems
Diabetes:
I am a diabetic
I am not a diabetic
Thyroid History
Hypothyroidism
Hyperthyroidism
Kidney History
Kidney stones
Kidney failure
Abnormal lab result
Hemodialysis
Peritoneal Dialysis
Other
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Pulmonary History
Click here to skip this section (pulmonary history)
I do not have respiratory conditions
Check all breathing conditions that apply
Seasonal allergies
Asthma/Wheezing
Chronic Bronchitis
Other
I have had COVID or other respiratory infection
Mild Symptoms
Moderate Symptoms
Severe Symptoms (hospitalized)
Other
COVID Month and Year
List residual or remaining or chronic symptoms
Emphysema/COPD
Wear O2 during the day
Wear O2 overnight
Sleep Apnea
I have sleep apnea
I don't have sleep apnea
Other respiratory concerns
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Musculoskeletal & Neurological History
Click here to skip this section (musculoskeletal & neurological history)
I do not have any muscle or joint pains, or neurological problems
Check all skeletal conditions that apply
Chronic back pain
Neck/spine surgery/fusion
Degenerative joint disease
Skull plate
Have you had a stroke?
TIA/Mini stroke
Stroke
Residual impairment?
Arthritis
MS
Numbness or tingling in hands and/or feet
Muscle Weakness in neck or back/paralysis
History of Migraine Headaches
Yes
No
Do you have Epilepsy?
Yes
No
Are you on anticonvulsants?
Yes
No
Do you have brain trauma/damage?
Yes
No
Do you have a spinal nerve stimulator?
Yes
No
Do you have an implanted drug delivery system?
Yes
No
Do you have surgical implants?
Yes
No
Seizures/Epilepsy: Month/Year of last seizure
Syncope: Month/Year of last episode
Check all neurological conditions that apply
Dementia
Parkinson's Disease
Alzheimer's Disease
Other
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Gastrointestinal & Hepatic History
Click here to skip this section (gastrointestinal & hepatic history)
I do not have gastrointestinal conditions or acid reflux
Check all gastrointestinal conditions that apply
Hiatal hernia
Hepatitis
Ulcers
History of gastric bypass
Other
Reflux
Severe - Not controlled, Occurs Daily
Moderate - Treated with medications
Mild - With certain foods only
Occasionally
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Hematologic History
Click here to skip this section (hematologic history)
I do not have any blood-based conditions
Check all blood conditions that apply
Anemia
Sickle cell disease
Sickle cell trait
History of blood clots
DVT
PE
Bleeding problems/Hemophelia
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Psychiatric History
Click here to skip this section (psychiatric history)
I do not have any history of mental illness
Check all conditions that apply
Anxiety
Depression
ADHD
PTSD
Bipolar disorder
Other
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Immunodeficiency History
Click here to skip this section (immunodeficiency history)
I do not have a compromised immune system
Check all immune system conditions that apply
HIV
Cancer
Chemotherapy
Radiation
Lupus
Other
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Pain Therapy
Check all pain diagnoses that apply
*
Chemotherapy-Induced Peripheral Neuropathy
Chronic Regional Pain Syndrome
Failed Back Surgery Syndrome
Chronic Post-Herpetic Neuralgia
Sciatic Nerve Pain
Chronic Back Pain
Spinal Stenosis
Post-Surgical Nerve Lesion Neuropathy
Brachial Plexus Neuropathy
Phantom Limb Pain Syndrome
Complex Regional Pain Syndrome,CRPS
Fibromyalgia
Other
Where is your pain primarily located?
*
Head
Neck
Abdomen
Upper-Mid Back
Mid-Back
Lower Back
Tailbone
Right Arm
Left Arm
Right Leg
Left Leg
Other
Pain Rating
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
How would you describe your pain?
*
Burning
Shooting
Throbbing
Cramping
Aching
Constant
Sharp
Dull
Intermittent
Other
Pain INCREASES with
*
Walking
Sitting
Standing
Activity
Other
Pain DECREASES with
*
Rest
Lying Down
Heat
Cold
Other
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Other Medical History
Last Menstrual Period
*
Not applicable
Period Start Date
Are you pregnant?
Yes
No
Breastfeeding?
Yes
No
Check all other conditions that apply
Glaucoma
Hearing Loss
Vision loss or blindness
Other
Please explain any illness, complaints, or hospitalizations in the last six (6) months:
By providing my digital signature, I acknowledge that I have read and answered the previous questions truthfully.
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