Ambulatory Surgery Center Location | Southern Orthopaedic Specialists, LLC

*Name:

*Date of Birth:

*Date of Surgery:

1. Have you ever undergone anesthesia before?

2. Have you/family had major problems (severe nausea, high fever, breathing difficulty) with surgery or anesthesia?

Do you now have or have you ever had:

3. Diabetes:

on pills

on insulin

4. High Blood Pressure:

on medicine

5. Cardiovascular Disease:

Angina/Chest Pain

Heart Failure

Irregular heart beat/Pacer/AICD

Valve disease/murmur
(including Mitral Valve Prolapse)

Heart Attack

Prior heart surgery/angioplasty /testing

6. What is your Activity Level?:

Limited

Climb 1 or more flights of stairs

Regular exercise

7. Lung Disease:

Emphysema

Shortness of breath

Asthma/wheezing

Sleep Apnea

CPAP?

8. Neuromuscular Disease:

Muscle Weakness

Paralysis

Rheumatoid Arthritis

Seizures

Stroke/TIA

9. Kidney Disease:

On Dialysis

10. Liver Disease:

Hepatitis/Jaundice

11. History of abnormal bleeding:

Blood transfusion

12. Digestive:

Hiatal Hernia

Acid Reflux

Ulcers

13. Back problems or chronic headaches?

Motion Sickness

14. Cold / Flu
Have you had a cold, "flu" or fever within the past week?

Have you taken oral or IV steriods within the past 6 months

15. Do you drink Alcohol?

Drinks/beers per day:

16. Do you smoke or have you in the past?

Packs per day:

Years smoking:

Quit when:

17. Do you take any of the following medications: Glucophage, Gluovance, Aspirin, Coumadin, Herbal medicines, Plavix, Ticlid, Aggrenox (you may need to discontinue these before surgery)

18. Do you have any loose teeth, caps, bridges, dentures or other dental work?
NOTE: Dental injury is a risk despite every precaution

19. Could you be pregnant?
Date of last menstrual period:

20. Do you have a history of pregnancy related complications? If pregnant, have you experienced any difficulties

21. Comments/Questions:

Surgery Center

Pre-Anesthesia Evaluation Form

Do you now have or have you ever had: