Preoperative Patient Questionnaire
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| GENERAL |
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| What is the date of your last menstrual period? |
MM/DD/YY |
| Do you have you any allergies? | YES / NO |
| Do you take any medication? | |
| ANESTHESIA | |
| Have you had anesthesia in the last 2 months? | |
| Has anyone in your family had a problem with anesthesia? | |
| Have you ever had any anesthetic problems? | |
| Do you have any teeth or swallowing problems? | |
| Do you have any problems with pain, stiffness or arthritis in your neck or jaw? | |
| HEART | |
| Have you ever had a heart attack? | |
| Have you ever been diagnosed with an irregular heartbeat? | |
| Do you suffer from angina or chest pain? | |
| Have you ever been diagnosed with heart failure? | |
| Do you get chest pain or breathlessness when you climb up two flights of stairs? | |
| RESPIRATORY | |
| Do you suffer from bronchitis or breathing problems? | |
| Do you suffer from asthma? | |
| BLEEDING | |
| Have you ever had a problem with bleeding or clotting? | |
| Have you ever had a stroke? | |
| DIABETES | |
| Do you have diabetes that requires insulin? | |
| Do you have diabetes that requires tablets only? | |
| COMORBIDITY | |
| Do you have kidney, liver, thyroid disease, epilepsy or seizures? |
Compiled by Jeffrey P. Johnson, DC, FNP-BC 2009; copyright Chronic Pain USA
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