PATIENT ANESTHESIA RECORD: SECURE FORM SUBMISSION


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Before you can proceed with the below form submission, we must ask that you review and accept St. Vincent's Health System Joint Notice of Health Information Privacy Practices. This policy describes the way that St. Vincent's Health System and any physician or other healthcare provider with medical staff privileges at St. Vincent's Health System will treat your health information about you created while you are a patient at St. Vincent's Health System.
To open a printable PDF (portable document format) version of the Joint Notice of Health Information Privacy Practices document, click here.
*Please Note: If the PDF version does not open or if it does not appear below, you will need Adobe Acrobat Reader. Click here to download a free copy of this program.


Patient Information

I Accept Acknowledgement of Receipt of Joint Notice of Health Information Privacy Practices.
I Decline Acknowledgement of Receipt of Joint Notice of Health Information Privacy Practices.

Full Name:    Date of Birth: (i.e. 01/01/2012)
Height:       Weight: lbs      Age:
1. Are you allergic to any medication(s)? If yes, please list below. Yes No
Please list medication(s) names you are taking along with the dosage and frequency for each.
** Please separate each med/dosage/ frequecy with a comma.
For example:
Allergra-D 1 tablet two times per day, Darvocet-N 1 tablet every 6 hours as needed

If you are NOT taking any medications, please type NONE in the box.
 
Please check YES or --- to the following: YES NO
2. Have you ever had surgery? If yes, please list 3 most recent surgeries with approximate dates.
3. Have you or a family member ever had a reaction to an anesthetic agent?
4. Have you personally, ever experienced nausea and vomiting after surgery? Do you have a history of motion sickness?
5. Do you have chest pain or shortness of breath when walking up 2 flights of stairs or 1 block?
6. Have you or any close relative ever had or been diagnosed with a muscular skeletal disease? If yes, please explain.
7. Do you have a history of ulcers, hiatal hernia, or frequent acid indigestion?
8. Do you have any problems with your heart? If yes, please list or explain.
9. Do you have high blood pressure?
10. Do you have any problems breathing? (Asthma, bronchitis, cold, cough, sleep apnea.)
11. Do you presently smoke tobacco? Packs per day  X years
12. Have you ever smoked? If so, when did you quit?
13. Do you drink alcohol? How many drinks per day?  
14. Have you ever had liver disease, yellow jaundice, cirrhosis, or hepatitis?
15. Have you ever had kidney disease or kidney failure?
16. Do you have sugar diabetes?
17. Do you have hyperthyroidism (high) or hypothyroidism (low)?
18. Have you ever had a stroke, seizure, or any other neurological disease?
19. Have you been diagnosed with a bleeding disorder?
20. Do you have any loose capped chipped false teeth? (CHECK THOSE THAT APPLY)
21. Do you have problems with your neck or jaw?
22. Have you taken any steroids, Prednisone ACTH, or Cortisone in the last year?
23. Do you use any recreational drugs (marijuana, cocaine, etc.)? If so, please list.
24. Do you or your parents have sickle cell disease or trait?
(CHECK THOSE THAT APPLY)
Yourself Father Mother
25. Have you taken any diet pills in the last 72 hours?
26. Any other health problems that we have not mentioned?
Your Full Name:
   Date: 		   

Reviewed by: ______________________________________________________     Date:__________________________
Anesthesiologist/CRNA

    
FEMALES ONLY    
27. Are you now or is there a chance you are pregnant?
Last menstrual period:    
28. Have you had a hysterectomy or tubal ligation?
I understand I may be tested for pregnancy. (Please type in your name below)