QUESTIONNAIRE

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To provide optimum care, your anesthesiologist must know your medical history in detail. Please be prepared to discuss the following items.

1. Allergies to medicines, eggs (lecithin), or latex.
   
   
2. Medications currently being taken. Please include any herbal or “natural” medications and weight control medications.
   
   
3. Prior operations requiring anesthesia. Any history of problems with anesthesia or family history such as high fever or the need for a respirator after anesthesia?
   
   
4. The name and phone number of your primary physician, family physician, or internist. (If you have a new primary physician who does not yet know you, the name and number of your former physician would be helpful.)
   
   
5. Heart problems such as chest pain, irregular heartbeat, congestive heart failure, heart murmurs or high blood pressure.
   
   
6. Breathing problems such as asthma, wheezing, recent or recurrent bronchitis, pneumonia. If you smoke, how much? If you quit smoking, when?
   
   
7. Liver problems such as hepatitis or jaundice. If you drink, how much?
   
   
8. Stomach problems such as heartburn, acid reflux, or regurgitation.
   
   
9. Kidney problems such as stones, infection or insufficiency.
   
   
10. Fainting spells, seizures, stroke, weakness or numbness in any part of your body. Headaches (sinus, tension or migraine?).
    
    
11. Neck or back problems?
    
    
12. Endocrine problems such as diabetes or thyroid disease. Have you taken steroid medications such as prednisone or cortisone.
    
    
13. If you are female and less than 50 years old, last menstrual period? How do you avoid pregnancy? (Birth control pills? Abstinence?).
    
    
14. Sleep apnea, or periods where you snore so heavily that you stop breathing for a few seconds. If you use a CPAP machine, please be prepared to bring it with you.