Test Form1 Thank you for visiting our web page. If you need additional information, please give us a call or you can fill in and submit the form below. Oklahoma Kidney Stone Center Anesthesia Questionnaire and EvaluationName First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Oklahoma ZIP Code PhoneEmail 1. Heart problems, congestive heart failure, heart attack, high blood pressure, heart murmur, abnormal electrocardiogram, blood clot, pacemaker/defibrillator Yes No 2. Lung disease: asthma, emphysema, bronchitis, abnormal chest x-ray, tuberculosis, sleep apnea. Yes No 3. Seizure, glaucoma, nervous system disease, stroke, muscle weakness, paralysis. Yes No 4. Jaundice, hepatitis, cirrhosis. Yes No 5. Kidney of bladder disease, stones, or severe infection Yes No 6. Metabolic problems: diabetes, thyroid, adrenal, etc. Yes No 7. Back injuries or surgery, broken bones. Yes No 8. Stomach or intestinal problems, ulcers, colitis, hiatal hernia, reflux, gastric Yes No 9. Blood transfusions: Date Yes No Blood transfusions Date Date Format: MM slash DD slash YYYY 10. Objections to blood transfusions. Even if your life is in danger? Yes No 11. Appropriate blood transfusion refusal form signed. Yes No 12. Blood disease, abnormal bleeding tendencies. Yes No 13. Anticoagulant therapy (Blood thinners). Yes No 14. Have you been tested for HIV/AIDS? Yes No 15. Are you pregnant? Yes No May be Last menstrual period date? Date Format: MM slash DD slash YYYY 16. Other medical illness Yes No 17. Have a history of DVT/PE? Yes No AgeHeightWeight (in lbs)When did you last have anything to eat or drink?Medication or Food Allergies: Yes No None Do you:1. Smoke? Yes No Packs/day For YearsQuit smoking? Date Date Format: MM slash DD slash YYYY 2. Use alcohol? None Socially Moderately Heavily 3. Have a history of substance abuse? Yes No 4. Wear eyeglasses? Yes No Wear contacts? In Out 5. Dentures: Upper Lower Bridges: Upper Lower Caps: Upper Lower None 6. Loose or damaged teeth: Upper Lower None 7 . List previous surgeries and dates: Date Format: MM slash DD slash YYYY Name of the surgery8. Have a problem to discuss with an anesthesiologist? Yes No 9. Have you ever had an abnormal anesthetic reaction? Yes No 10. Do you have any relatives with abnormal anesthetic reactions? Yes No Medications/Herbs/Vitamins: (List all medications/dose taking)I understand this information is important to my medical care and is correct.Date/Time Date Format: MM slash DD slash YYYY : HH MM AM PM Patient SignatureAnesthesia Evaluation (Anesthesia to complete)Date Date Format: MM slash DD slash YYYY Time : HH MM AM PM NPORx medication(s) before surgeryHistory:Physical:Time : HH MM AM PM CVPlumNeuroAnesthesia benefits/options with attendant risk and complications discussed with patient/family. Questions answered. Yes No Procedure proposedDental/Airway:PlanInformed consent given byCRNAAnesthesiologistAdmit to RecoveryDate Date Format: MM slash DD slash YYYY Time : HH MM AM PM O2 satBPPRTempCRNA:Anesthesiologist:Time care turned over to PACU nurse:Post Anesthesia EvaluationDate Date Format: MM slash DD slash YYYY Time : HH MM AM PM O2 satBPPRTempNeuro/LOC: WNL CV: WNL Pulm: WNL Complications: None Anesthesiologist