Test Form1 | Oklahoma Lithotripter Associates

Oklahoma Kidney Stone Center Anesthesia Questionnaire and Evaluation

Name

First Last

Address

Street Address Address Line 2 City Oklahoma ZIP Code

Phone

Email

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

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?

16. Other medical illness

Yes
No

17. Have a history of DVT/PE?

Yes
No

Age

Height

Weight (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 Years

Quit smoking? Date

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:

Name of the surgery

8. 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

: HH

MM

Patient Signature

Anesthesia Evaluation (Anesthesia to complete)

Date

Time

: HH

MM

NPO

Rx medication(s) before surgery

History:

Physical:

Time

: HH

MM

CV

Plum

Neuro

Anesthesia benefits/options with attendant risk and complications discussed with patient/family. Questions answered.

Yes
No

Procedure proposed

Dental/Airway:

Plan

Informed consent given by

CRNA

Anesthesiologist

Admit to Recovery

Date

Time

: HH

MM

O2 sat

BP

P

R

Temp

CRNA:

Anesthesiologist:

Time care turned over to PACU nurse:

Post Anesthesia Evaluation

Date

Time

: HH

MM

O2 sat

BP

P

R

Temp

Neuro/LOC:

WNL

CV:

WNL

Pulm:

WNL

Complications:

None

Anesthesiologist