AIRWAY

Do you have removable partial plates/bridges
Do you have permanent plates/bridges
Do you have loose teeth
Do you have chipped teeth
Do you have difficulty opening your mouth
Do you have any difficulty moving you neck
Has an anesthesiologist ever told you that he/she had difficulty placing a “breathing tube” in your throat or wind pipe?

ANESTHESIA

Have you ever experienced a lift threatening reaction because of anesthesia
Has any member of your family ever experienced a life-threatening reaction because of anesthesia
Do you suffer from motion sickness
Have you ever been sick to your stomach (nauseous) or vomited after anesthesia
Have You Had Any Episode(S) Of Dark Urine
Have You Had Any Episode(S) Of Prolonged Fever After Anesthesia
Have You Had Any Episode(S) Of Paralysis After Anesthesia

NEUROLOGY

Have You Ever Had A Stroke
Have you had a seizure?
Have you ever fainted or “blacked-out” within the last year

CARDIOVASCULAR

Do you suffer from high blood pressure
Do you have a history or heart disease
Have you ever had a heart attack
Have you ever had heart surgery
Do you suffer from congestive heart failure
Do you have a heart murmur or problem with one of your heart valves
Have you ever been told by a doctor that you have and “irregular” or “abnormal” heartbeat
Were you born with an abnormal heart that required heart surgery in infancy or early childhood
Do you have a pacemaker or Automatic Internal Cardiac Defibrillator (AICD)
Have you ever had any special heart tests like stress tests echocardiograms cardiac catheterization
Have you have any heart Setents
Did You Have Heart Surgery In Childhood/Infancy
Did You Have a defibrillator

RESPIRATORY

Have you had a cold or the flu recently
Do you have a history of lung disease
Do you suffer with asthma
Do you suffer with chronic bronchitis
Do you have emphysema
Do you have Chronic Obstructive Pulmonary Disease (COPD)
Do you snore
Do you have difficulty staying awake during the daytime
Do you suffer from sleep apnea
Do you use a CPAP machine

GI

Do you have a hiatal hernia
Do you have acid reflux
Do You Have A History Of Ulcers?

Hematology And Oncology

Do you, or have you had cancer
Did You Receive Radiation Treatment
Did You Receive Chemotherapy Treatment
Have you ever had a blood transfusion
Do you have a personal or religious objection to receiving blood or blood products during, or after your surgery-even if doing so would be lifesaving
Do you bleed or bruise easily
Do your gums bleed
Do you or any member of your family have an inherited bleeding disorder (Hemophilia A or B, Von Willebrand's disease, Factor 7 or 11 Deficiency etc.)?
Do you have sickle cell anemia or sickle cell trait
Do you take Coumadin Warfarin Lovenox Heparin Plavix Aspirin Ticlid Pletal Naproxen Ibuprofen Enosaparin
Have you ever been told by a doctor that you suffer from anemia or a low blood count
Do You Or Any Member Of Your Family Have An Inherited Bleeding Disorder
Do You Have A Personal Or Religious Objection To Receiving Blood Or Blood Products During, Or After Your Surgery
Have You Ever Been Diagnosed With Hepatitis?

RENAL

Has a doctor ever told you that your kidneys do not work as well as they should
Do You Have Kidney Disease?
Do you suffer from chronic kidney failure
Have you ever had surgery on either of your kidneys

ENDOCRINE

Do you have a history of diabetes
Do you have high cholesterol
Do You Have Thyroid Disease?

MUSCULOSKELETAL

Do you suffer from rheumatoid arthritis
Do you suffer from chronic pain

Allergies & Medication Supplements

Do you have allergies to medications
Do you have allergies to foods
Do you have allergies to eggs
Do you have allergies to betadine/iodine
Do you have alleries to IV contrast
Do you have allergies to latex
Are you on Beta-blockers
Do you take herbal supplements
Do you take Vitamin E Vitamin B6 Vitamin K Calcium Potassium
Do You Take Any Antacids?

EXERCISE TOLERANCE

Do you ever get chest pain, tightness, or pressure with activity (walking, running, climbing stairs, lifting something heavy)?
I can run several miles or participate in vigorous sports and activities
I can do heavy exercise, dance or run up 3 flights of stairs.
I can walk long distances without limitation, do heavy lifting, or climb 3 flights of stairs quickly
I can run for short distances
I can walk several miles on level ground or climb 3 flights of stairs without stopping
I can walk up a hill, or climb 2 flights of stairs if I take my time
I walk four blocks on level ground and do light work (dusting, dishwashing) around the house.
I can walk only 1-2 blocks on ground level if I take my time.
I can walk between the room of my home, but tire very easily
I can eat, get dressed or use the bathroom, but I am exhausted when finished
I can only take several steps before getting severely short of breath

Social Lifestyle

Do you smoke
Do you drink 2 or more servings of alcohol per week
Do you take recreational drugs
Have You Traveled Outside The United States Within The Last Three Weeks
Have You Experienced Any Of The Following Symptoms Since Your Return (Fever Higher Than 101.5f, Vomiting, Diarrhea, Headache, Sore Throat, Abdominal Pain Or Malaise)?

WOMEN ONLY

Are you pregnant
Is it possible that you could be pregnant
Do you have heavy periods

MEN ONLY

Do you take any erectile dysfunction medication