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Pre-Anesthesia Assessment Form

FAILURE TO PROVIDE ACCURATE INFORMATION MAY RESULT IN CANCELLATION OF YOUR CASE

Pre-Anesthesia Assessment Form

Facility Name:

Facility Location:

Procedure Date:

Patient's First Name

Patient's Last Name

Preferred to be called:

Preferred Pronouns

Date of Birth:

Age:

Patient's age (in years).

Patient's Phone #s:

Patient's Email:

Patient's Address:

Address Line 1

Address Line 2

City

State

Zip Code

Gender (assigned at birth):

Male

Female

Height:

*in feet and inches.

Weight:

*in pounds.

BMI:

Primary Care Physician Name:

Primary Care Physician Phone Number:

Primary Care Physician Address:

Address Line 1

Address Line 2

City

State

Zip Code

PCP last visit date [if known]

Specialists with contact information: (i.e., cardiologists, allergist, rheumatologist, etc.):

Specialist last visit date:

Current Medications (prescription, non-prescription, vitamins/ herbal supplements):

Food and Drug Allergies (please include reactions)/ Latex:

Prior Surgeries / Procedures (please provide date of prior surgeries):

Please check “YES” or “NO” and write detailed additional comments next to each condition:

** Please list all medical conditions! **

Recent Cold / Flu /Covid:

Yes

No

Additional Comments:

Chest Pain / Chest Tightness or Pressure/ Angina:

Yes

No

Additional Comments:

Heart Attack (MI) / Congestive Heart Failure/ Irregular Heartbeat (i.e. Atrial Fibrillation, etc.)

Yes

No

Additional Comments:

Angioplasty / Cardiac Stent/ Pacemaker or Defibrillator:

Yes

No

Additional Comments:

High Blood Pressure/ Blood Clots (DVT or PE) / Circulation Problems:

Yes

No

Additional Comments:

Asthma/ COPD / Emphysema / Shortness of breath (SOB):

Yes

No

Additional Comments:

Can you walk 3 or more blocks without having shortness of breath? ** If no, please document your daily activity level:

Yes

No

Additional Comments:

Sleep Apnea / CPAP / Severe Nighttime Snoring:

Yes

No

Additional Comments:

Liver / Kidney Disease:

Yes

No

Additional Comments:

Acid Reflux / Heartburn/ Hiatal Hernia:

Yes

No

Additional Comments:

Stroke/ TIA / Seizures/ Back or Neck issues: ** If so, any deficits / residual weakness?

Yes

No

Additional Comments:

Paralysis / Muscle Disorder / Nerve Disease / MS / Muscular Dystrophy:

Yes

No

Additional Comments:

Bleeding Problems / Easy bruising:

Yes

No

Additional Comments:

HIV/ AIDS/ Hepatitis/ Sickle Cell Disease:

Yes

No

Additional Comments:

Diabetes (type) / Thyroid problems:

Yes

No

Additional Comments:

Anxiety/ Depression/ ADHD/ Other Psychiatric Conditions:

Yes

No

Additional Comments:

Cancer/ Chemotherapy/ Radiation Therapy:

Yes

No

Additional Comments:

Eye or Ear Disorders/ Cataracts/ Glaucoma/ Retinal Det./ Hearing Loss:

Yes

No

Additional Comments:

Any other condition(s) not listed above?

Can you climb a flight of stairs quickly, or walk briskly for 3 blocks?

Do you smoke cigarettes?

Yes

No

How many packs a day?

For how many years?

Did you quit smoking?

Yes

No

Year of quitting

*just the year when you quit smoking.

Do you use vaping products?

Yes

No

Alcohol use?

Yes

No

Frequency:

Quantity of Alcohol use:

Substance Use: Past or Present(including Cannabis):

Yes

No

Type of Substance:

Last used:

Possibility of Pregnancy:

Yes

No

N/A

Have you ever been infected with COVID since the pandemic started?

Yes

No

Unknown

Have you ever been hospitalized for COVID infection?

Yes

No

N/A

Any unusual reaction to anesthesia in the past (nausea/ vomiting/ difficult intubation/ Malignant Hyperthermia)?

Yes

No

Never Had Anesthesia

** If YES, please list the procedure, type of reaction, and the length of that procedure:

Any other special concerns / religious objections for the anesthesia provider?

SIGNATURE

Please sign the form by filling out the fields below.

I hereby authorize ATLAS ANESTHESIA P.C. to obtain all medical records relevant to my upcoming procedure:

First Name

Last Name

Relation to patient:

Date

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Pre-Anesthesia Form

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Pre-Anesthesia Assessment Form

**FAILURE TO PROVIDE ACCURATE INFORMATION MAY RESULT IN CANCELLATION OF YOUR CASE**

FAILURE TO PROVIDE ACCURATE INFORMATION MAY RESULT IN CANCELLATION OF YOUR CASE