University Hospitals of Cleveland
Department of Anesthesiology
PRE-ANESTHESIA HEALTH QUESTIONNAIRE
Main Campus (PAT): Tel 216-844-1066 Fax 216-844-5399
Mentor ASC: Tel 440-205-4505 Fax 440 205 4515 | Westlake ASC: Tel 440 250-2440 Fax 440 250-2404
Richmond Hts Hospital: Tel 440 585-6480 Fax 440 585-6174 | St Michael's Hospital: Tel 216 429-8480 Fax 216 429-8184
OFFICE USE ONLY
Surgeon: Hospital #:
Surgical Procedure: Procedure Date:
Please provide identifying information, then answer ALL the following questions (both pages), about your health. Answer “YES” or “NO” or
“UNSURE”. If you answer “YES” to a particular question, please mark any of the options listed below the question that apply to you.
Patient Name: Age: Sex: Height: Weight:
Completed By (Sign): Relationship to Patient: Self Other Date:
1. Have you ever had a HEART condition, HEART procedure, or HIGH BLOOD PRESSURE? NO YES UNSURE
Heart attack……….Date: ___/___/______ High blood pressure High cholesterol
Angina or chest pain Heart murmur Abnormal electrocardiogram (EKG)
Irregular heart beat or palpitations Heart valve problem Heart or bypass surgery
Congestive heart failure Congenital heart disease (born with a heart Angioplasty, stent or “balloon” procedure
("fluid on the lungs") problem) Pacemaker or defibrillator
Other heart condition or procedure (DESCRIBE) ………………………………………………………………………………………………………………..
2. Have you had BREATHING problems or a LUNG condition? (select any that apply below) NO YES UNSURE
Asthma Short of breath when lying down flat Sleep apnea or very loud snoring
Emphysema or COPD Recent cold, respiratory infection, fever or Home ventilator, CPAP or BiPAP
Chronic cough With phlegm chills (last 2 weeks) Use oxygen at home
Recent pneumonia (last 2 months) Blood clot in lungs (pulmonary embolism)
Other lung or breathing problem (DESCRIBE) …………………………………………………………………………………………………………………..
3. Do you have a LIVER, KIDNEY or PROSTATE condition? (select any that apply below) NO YES UNSURE
Kidney failure Hepatitis or Jaundice Prostate cancer
Blood hemodialysis Peritoneal dialysis Cirrhosis of the liver Enlarged prostate
Other (DESCRIBE) ………………………………………………………………………………………………………………………………………………….
4. Do you have DIABETES, or a THYROID condition? (select any that apply below) NO YES UNSURE
Diabetes Hypothyroid (underactive thyroid Other ………………………………………………
Insulin treatment Hyperthyroid (overactive thyroid) …………………………………………………………
5. Do you have an ORAL, DIGESTIVE or WEIGHT problem? (select any that apply below) NO YES UNSURE
Chipped, loose or fragile teeth Take diet medications Obesity (overweight) –please provide your
Acid reflux, heartburn or hiatal hernia Severe weight loss or undernourished height and weight above
Other (DESCRIBE) …………………………………………………………………………………………………………………………………………………
6. Do you have a BRAIN, NERVE, MUSCLE or MENTAL HEALTH condition? NO YES UNSURE
Stroke or TIA (“mini-stroke”) Numbness or weakness (hands/feet/face) Myasthenia gravis Anxiety (severe)
Seizures or epilepsy Carpal tunnel Multiple sclerosis Muscle disease
Other (DESCRIBE) …………………………………………………………………………………………………………………………………………………..
7. Do you have a BLOOD disorder? (select any that apply below) NO YES UNSURE
Anemia (low blood count) Abnormal bleeding or bruising Other…
……………………………………………….
Sickle cell disease Thrombosis (blood clot) ………………………………………………………..
8. Do you have ARTHRITIS, SPINE or JOINT problems? (select any that apply below) NO YES UNSURE
Rheumatoid arthritis “TMJ” (jaw joint problems) Spine problems: Neck Upper back
Osteoarthritis (degenerative) arthritis Lower back (sciatica)
Other (DESCRIBE) ………………………………………………………………………………………………………………………………………………….
University Anesthesiologists, Inc. © 2002-2003. All rights reserved. Version: 030703.
9. Have you had CANCER? (select any that apply below) NO YES UNSURE
Type of cancer: …………………………… Chemotherapy (“chemo”) (last 3 months)
……………………………………………… Radiation treatments (last 3 months)
10. Do you become short of breath with any of the activities listed below? (Select the activity) NO YES UNSURE
Climb a flight of stairs Heavy house work e.g. scrubbing floors, lifting or moving furniture?
Walk up a hill Run a short distance
10a. Describe any regular PHYSICAL EXERCISE that you do _____________________________________________________________________
11. Have you SMOKED cigarettes? Do you drink ALCOHOL or use DRUGS? NO YES UNSURE
Cigarette smoking ___ packs per day Alcohol ____ Drinks per week Marijuana
____ years of smoking Cocaine
Other drugs (DESCRIBE) ……………………………………………………………………………………………………………………………………….
12. Have you ever had SURGERY? (Please list with dates) NO YES UNSURE
1) …………………………………………… 4) …………………………………………………..
2) …………………………………………… 5) …………………………………………………
3) …………………………………………… 6) …………………………………………………..
12a. If you had surgery, did you ever receive a BLOOD TRANSFUSION? NO YES UNSURE
13. Any previous DIFFICULTIES or COMPLICATIONS with anesthesia or surgery? NO YES UNSURE
Difficult intubation (breathing tube insertion) Severe nausea or vomiting Malignant hyperthermia (you or family member)
Difficulty waking up Awareness (remembered being in surgery) Family member had major anesthesia problem
Other (DESCRIBE) ………………………………………………………………………………………………………………………………………………
14. Are you HIV positive? Do you have AIDS or any other infectious disease? NO YES UNSURE
HIV positive AIDS Otherr ……………………………………………
15. WOMEN: Is there any chance that you are now PREGNANT? NO YES UNSURE
Please provide the date of your last menstrual period: _________(mm)/________(dd)/__________(yy)
16. Any OTHER MEDICAL CONDITION or CONCERN ABOUT ANESTHESIA OR SURGERY? NO YES UNSURE
Please DESCRIBE:
17. Have you SEEN YOUR DOCTOR or had MEDICAL TESTS in the last 3 months? (List) NO YES UNSURE
Blood tests EKG Chest X-Ray
Location where tests were done ……………………………………………………………………………………………………………….
Name of Primary Physician ______________________________ Telephone (if known): __________________________
18. Have you ever had any specialized HEART TESTS? (Please list below) NO YES UNSURE
Stress Test Echocardiogram (heart ultrasound) Heart catheterization (angiogram)
19. Do you take PRESCRIPTION MEDICINES? NO YES UNSURE
Please list names & dose if known (use separate sheet if needed):
1) ………………………………………………… 4) …………………………………………………… 7) …………………………………………………….
2) ………………………………………………… 5) …………………………………………………… 8) …………………………………………………….
3) ………………………………………………… 6) …………………………………………………… 9) ……………………………………………………
20. Do you take OVER-THE-COUNTER MEDICINES or HERBAL PREPARATIONS? (Please list) NO YES UNSURE
1) ………………………………………………… 3) …………………………………………………… 5) ……………………………………………………
2) ………………………………………………… 4) …………………………………………………… 6) ……………………………………………………
21. Do you have any ALLERGIES to medicines or to latex rubber? (Please list below) NO YES UNSURE
1) ………………………………………………… 3) …………………………………………………… 5) ……………………………………………………
2) ………………………………………………… 4) …………………………………………………… 6) ……………………………………………………
University Anesthesiologists, Inc. © 2002-2003. All rights reserved. Version: 030703.
University Anesthesiologists, Inc. © 2002-2003. All rights reserved. Version: 030703.
