Form – Atlasanesthesia

Skip to content

Home
About
Services
Contact
FAQ

Get started

Home
About
Services
Contact
FAQ

Pre-Anesthesia Assessment Form

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

Anesthesia Questionnaire

Facility Name & Location:

Planned Procedure:

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, endocrinologist, rheumatologist, nephrologist, pulmonologist, pain medicine, etc.):

Specialist last visit date:

Current Medications (prescription, over-the-counter, vitamins/ herbal supplements):

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

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

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

** Please list all medical conditions! **

Recent Respiratory Infection/ 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.) / Fainting Spells:

Yes

No

Additional Comments:

Heart Surgery / Cardiac Stent/ Pacemaker or Internal Defibrillator:

Yes

No

Additional Comments:

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

Yes

No

Additional Comments:

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

Yes

No

Additional Comments:

Can you climb 3 flights of stairs without having shortness of breath? *** If no, please document your daily activity level:

Yes

No

Additional Comments:

Sleep Apnea / Loud Snoring/ CPAP or BiPAP use:

Yes

No

Additional Comments:

Liver or Kidney Disease/ Kidney Failure/ Dialysis:

Yes

No

Additional Comments:

Acid Reflux / Heartburn/ Hiatal Hernia:

Yes

No

Additional Comments:

Stroke/ TIA / Seizures/ Back, Neck or Joint Problems That May Affect Positioning Or Intubation: *** If prior stroke, any deficits / residual weakness?

Yes

No

Additional Comments:

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

Yes

No

Additional Comments:

Bleeding Problems / Easy Bruising/ Taking Blood Thinners:

Yes

No

Additional Comments:

HIV or AIDS/ Hepatitis/ TB/ MRSA/ Sickle Cell Disease:

Yes

No

Additional Comments:

Diabetes (type I or II) / Thyroid Disorders (Hyper or Hypo):

Yes

No

Additional Comments:

Anxiety/ Depression/ ADHD/ Bipolar/ Schizophrenia/ Other Psychiatric Conditions:

Yes

No

Additional Comments:

Cancer/ Chemotherapy/ Radiation Therapy:

Yes

No

Additional Comments:

Eye or Ear Disorders/ Cataracts/ Glaucoma/ Retinal Detachment/ Hearing Loss:

Yes

No

Additional Comments:

ANY OTHER CONDITION(s) NOT LISTED ABOVE?

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/ Opioids/ Other):

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:

Do you have a Living Will or medical Power Of Attorney (Healthcare Proxy)?

Yes

No

Any other Special Concerns / Religious Objections for anesthesiologist?

SIGNATURE

Please sign the form by filling out the fields below.

I hereby authorize ATLAS ANESTHESIA P.C. to contact any of my physicians and obtain all medical records relevant to my upcoming procedure:

First Name

Last Name

Relation to patient:

Today's Date:

Home
Services
Anesthesia Questionnaire
FAQ
Surgery Intake Form

Scroll to Top

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