Pre-Op Questionnaire RTC Pediatrics a Division of Trusted Doctors LLC
1830 Town Center Drive, Suite 205, Reston, VA 20190 703-435-3636 P 703-435-9145 F
Patient name
First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Today's date
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Month
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Day
Year
Date
1. What procedure is your child having?
Why?
2. Does your child have any of the following?:
Cardiac disease or murmur
Neuromuscular disease
Seizures
Asthma or Wheezing
Kidney or liver disease
Down Syndrome
Gastroesophageal reflux
Bleeding problems
Problems with previous anesthesia
Endocrine disorder
Prematurity
Loose tooth
Rheumatoid arthritis
Bowel or bladder problems
3. Is there a history in your family of:
Neuromuscular disease
Difficulty with anesthesia
Bleeding tendencies
Hemoglobin abnormalities
4. What medication(s) is your child on?
5. Does child have any allergies?
6. Has child had any procedures or hospitalizations prior to this?
6.1 Hospital
6.2 Reason
6.3 Date
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Month
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Day
Year
Date
Submit
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