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Patient Questionnaire

* Indicates required information
Surgeon:
Date of Surgery:
Procedure:
(Patient's Legal Name) Last Name: *
First Name: *
Middle Initial:
Nickname:
(Patient's) Date of Birth: *
Home Phone Number: *
Parent/Legal Guardian:
Work Phone Number:
Cell Phone Number 1:
Cell Phone Number 2
Additional Contact Number
Parent's E-mail Address
(Patient's) Primary Care Physician
Physician Office Number:
Patient's current MEDICATIONS: (including nebulizer, aerosol, herbal, over-the-counter):
Patient's ALLERGIES: (Ex. none, foods, drugs or latex):
Will the Patient spend the night in the hospital after the surgery/procedure?	Yes No Don't Know None
Was the patient born early?	Yes No Don't Know None
If so, how many months/week early?
Patient's Birth complications:
Has the patient ever had general anesthesia (been put to sleep)?	Yes No Don't Know None
If so, what is the name of the hospital where the general anesthesia was administrated?
Did the patient have any problems with being put to sleep or waking up from the anesthesia?	Yes No Don't Know None
(Difficulty passing the endotrachael tube, high fever, rash, breathing problem, excessive nausea, etc) If so, explain:
Have any of the patient's blood relatives ever had anesthesia complications?	Yes No Don't Know None
(Malignant hyperthermia, problems with Anectine, pseudocholinesterase deficiency, etc:) If so, please explain:
Do any of the patient's blood relatives have a bleeding disease or blood disorder?	Yes No Don't Know None
(Hemophilia, Von Willebrand's Disease, Sickle Cell Disease/Trait, Thalassemia, etc:) If so, please explain:
Do any of the patient's blood relatives have a muscle disease?	Yes No Don't Know None
(Muscular Dystrophy, Spinal Muscular Atrophy, Friedreich's Ataxia, etc.:) If so, please explain
Does the patient have any metal objects or surgical hardware in their body?	Yes No Don't Know None
If so, Where?
Has the patient been sick in the last week (cold, stomach virus, etc.)?	Yes No Don't Know None
Has the patient had bronchitis, croup, pneumonia or flu in the last 4-6 weeks?	Yes No Don't Know None
Does the patient bruise or bleed easily?	Yes No Don't Know None
Has the patient been exposed to a contagious illness recently? (ex. ring worm, pink eye, lice, chicken pox)	Yes No Don't Know None
Does the patient have any problems opening the mouth or moving the head/neck?	Yes No Don't Know None
If the patient is female has she started her menstrual cycle?	Yes No Don't Know None
If so, list the date of the last period
Are there any cultural/religious beliefs that would change the plan of care at CHS (no blood product)?	Yes No Don't Know None
Does the patient see any speciality doctors (cardiology, pulmonary, neurology, endocrinology, etc)?	Yes No Don't Know None
If so, please list specialty doctor's names
Has the patient ever had any of the following conditions? Check all that apply.	Abnormal Sickle Cell Trait Airway Problems Anemia Arthritis Asthma/Wheezing/Reactive Airway Disease (RAD) Birth Defects Cerebral Palsy (CP) CPAP/BiPAP Croup (Recurrent) Cystic Fibrosis (CF) Diabetes Glaucoma Heart Disease or Condition Heart Murmur Hemophilia Hepatitis High/Low (BP) Blood Pressure History of Organ Transplantation Home Oxygen Home Ventilator (vent) Jaundice Kidney Disease Laryngomalacia Liver Disease Malignant Hyperthermia Rheumatic Fever Seizures Sickle Cell Disease Sleep Apnea Stomach (acid) reflux Subglottic Stenosis Syndromes Thalassemia Thyroid Disease Tracheostomy (trach) Tuberculosis (TB) Von Willebrand's Disease Hydrocephalus Autism Spina Bifda Developmental Delay
If the patient has any existing conditions not lin the list, please list here
Full Name of person completing questionnaire
Choose Your Relationship to the Patient (For questions about the online form please call 205-939-6235)

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