Preoperative Questionnaire Questions for the Pre-Surgical Candidate

Senior Man - Monitored Exercise 

Preoperative Patient Questionnaire

 

 

 

GENERAL

 

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

One Response to Preoperative Questionnaire

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