Pre-surgery Anesthesia Questionnaire Name * First Name Last Name AGE Height * Feet and Inches Weight * Pounds Phone * Best contact number (###) ### #### Email * List Medications you take * Do you take any blood thinners? * Yes No Only Aspirin List all Allergies to Medications * List Major Surgeries Have you been told you have a difficult airway? YES NO Have you had any problems with Anesthesia? YES NO Do you or any family members have Malignant Hyperthermia? Yes No Do you have sleep apnea? * NO Not sure but I snore YES Yes, I wear a CPAP Do you have any Heart Disease? * Check all that apply NO Heart Disease High Blood Pressure High Cholesterol Chest Pain with activity (Angina) Heart Attack in the past Murmur or Heart Valve disease Aortic Stenosis Congestive Heart Failure/ Cardiomyopathy Heart Stent or Heart Surgery Pacemaker or AICD Abnormal Heart Rhythm, Atrial Fibrillation Other Do you have any Lung problems? * NO Lung Problems Recent Cold, Flu or Upper respiratory infection Asthma Bronchitis COPD Emphysema History of Lung Cancer I cannot sleep lying flat I am on home oxygen Other Do you have any Neurologic or Musculoskeletal problems? * Select all that apply NONE Arthritis MS, Neuromuscular disease Paralysis or weakness Stroke or TIA Vertigo or Syncope ( passing out) Dementia or Alzheimers Parkinsons Seizures Migraines Fibromyalgia or Chronic pain Back or Neck surgery Anxiety or Depression Other Do you have any Endocrine problems? * Select all that apply NO Hypothyroid, low thyroid Hyperthyroid Diabetes, I am taking Insulin Diabetes, I am taking oral medications Pre-Diabetes I am taking steroids Other Do you have any Kidney problems? Select all that apply None History of Kidney stones Chronic Kidney disease Renal Failure Dialyses Cancer Other Do you have any Gi or Liver problems? * Select all that apply None Reflux Hiatal Hernia Peptic Ulcer Disease Ulcerative colitis or Crohns Nausea, Vomiting Hepatitis Elevated Liver function tests, Jaundice Cirrhosis Other Are you Post-Menopausal? Females only* Choose below Yes No I have had a Hysterectomy Do you smoke? * Never I used to smoke but quit Yes, less than a pack per day Yes, 1 pack per day Yes, more than 1 pack per day Do you drink Alcohol? No Yes, 1-3 times a week Yes, daily Yes, Rarely COVID screening * No symptoms of Fever, Cough, shortness of breath) Yes I have symptoms (Fever, Cough, shortness of breath) Recent exposure to COVID ( last 2 weeks) List any other information or concerns Thank you for completing your pre-anesthesia form