Pre Anesthesia Assessment Form

Please call 573-651-5830 for questions regarding this form.

This information will be reviewed by your Anesthesiologist prior to surgery and will help to prepare and provide safe anesthesia and nursing care for you.

Patient Information
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Do you have heart stents?

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Type of Stent

Select All that Apply

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Do you take any of the following?

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Do you have a latex allergy?

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Have you had significant weight loss in the last 6 months without dieting?

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Medications (prescribed and over the counter)
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Cardiovascular Disease
Do you have or have you ever had a history of:








Respiratory Disease
Do you have or have you ever had a history of:



Do you use oxygen at home?

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If you answered yes above, when do you use oxygen?

Do you or have you ever smoked?

Have you quit smoking?

Do you use chewing tobacco?

Neurological Disorder
Do you have or have you ever had a history of:




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Diabetes
Do you have or have you ever had a history of:



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Thyroid Problems
Do you have or have you ever had a history of:


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Kidney / Bladder / Prostate Disorder
Inability to urinate after anesthesia?

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Dialysis

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Gastro-Intestinal Disease
Do you have or have you ever had a history of:

Blood Disorder
Do you have or have you ever had a history of:







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Eye Disorder / Glaucoma / Retinal Detachment
Do you wear:


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Do you have or have you ever had:

Ear Disorder / Ringing in Ears / Hearing Loss
Do you have hearing aides?

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Cancer / Chemotherapy /Radiation Therapy
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Psychiatric Disorder
Other Illness or Disease
For Women
Have you had or are you:


Could you be pregnant?

For Pediatric Patients
Was the child born prematurely?

Were there complications with the delivery?

Was the child born via C-section?

Was the child in the NICU?

Anesthesia Related Information
Please check all that apply to your anesthesia history:








Are you aware of the risk of eating or drinking the day of your anesthesia?

Do you take antibiotics prior to having dental work?

Because drugs may interact adversely with anesthesia, please indicate the following:
Do you have a history of regular alcohol use?

Have you used steroids/cortisone in the past year?

Do you or have you ever used drugs recreationally?