The intention of this questionnaire is to help your anesthesiologist select the proper technique for you.

Weight ________________
Height _________________
Physical activity now: LITTLE: ______ MODERATE: ______ VERY ACTIVE: _______
Can you climb stairs? YES ______ NO_______ NUMBER OF FLIGHTS 1____ 2____ 3____ YES NO

FAMILY HISTORY
HAS ANYONE IN YOUR FAMILY:
Had a tendency to bleed excessively? ____ ____
Had unusual reactions to anesthesia? ____ ____
Had unexplained fevers during or following surgery? YES NO

YOUR MEDICAL HISTORY:
Are you allergic to ANY medicines? If yes, what? _______________________
What kinds of reactions do you have? _________________________________
Do medicines have an unusual effect on you? If yes, what effect? __________
Are you allergic to adhesive tape? _________ Iodine? _________
Do you have alcoholic drinks more than 2 or 3 times a week?
If yes, how much and what do you drink each day? _____________________________________
Have you ever had alcoholic withdrawal? (DT's) ___________________________
Do you smoke? If yes, how many cigarettes a day? ______________________
Have you ever had a blood transfusion? ________________________________
Is there any possibility of your being pregnant at this time? ________________ YES NO

HAVE YOU EVER HAD...? and WHEN
Heart Disease? ___________
Heart Attack? ___________
High Blood Pressure? ___________
Stroke? ___________
Palpitations(irregular heart beat)? ___________
Chest Pain? ___________
Abnormal Shortness of Breath? ___________
Asthma or frequent wheezing? ___________
mphysema? ___________
Bronchitis? ___________
Tuberculosis? ___________
Hepatitis (Yellow Jaundice)? ___________
Serious illness during pregnancy? ___________
Thyroid Disease? ___________
Kidney Disease? ___________
Diabetes Melitus? ___________
Easy bruising or bleeding? ___________
Blood Disorders? ___________
Glaucoma? ___________
Frequent Headaches? ___________
Nerve Paralysis? ___________
Fainting Spells? ___________
Epilepsy (Seizures)? ___________
Backpain/back problems? ___________
Other Nervous System Disease? ___________
Phlebitis? ___________
Arthritis? ___________
Drug Addiction? ___________ YES NO

WHAT KIND OF ANESTHESIA HAVE YOU HAD BEFORE? ____
Epidural/Saddle/Spinal block? ____
General (Completely asleep)? ____
Pentothal? ____
Local or nerve blocks? ____
Have you ever had any unusual reactions, problems or complications with anesthesia? (e.g., jaundice, high fever, paralysis, breathing problems) YES NO

DO YOU...?
Wear removable dentures? ____
Contact Lenses? ____
False Eyelashes? ____
Have permanent porcelain caps on your teeth? ____
Have difficulty with movement of your head or neck? ____
Have a false eye? ____
Have any teeth loose or chipped? ____
Have you any major physical or congenital defects? ____
Have difficulty fully opening your mouth? ____
Have you had problems with your voice or surgery on your vocal cords?
Approximate date of last physical examination _________ XRay________ EKG __________

MEDICATIONS: Please list names and doses of any medications you now take or have taken within the last six months. _____________

If you have taken any illicit drugs, please tell the Anesthesiologist! INFORMED CONSENT FOR ANESTHESIA Modern anesthesia is safe and usually well tolerated. However, even in experienced and competent hands, complications can occur. Minor problems include NAUSEA AND VOMITING, HEADACHES, INJURY TO TEETH OR DENTAL WORK, OR INJURY TO VOCAL CORDS CAUSING HOARSENESS EITHER TEMPORARILY OR PERMANENTLY. Serious complications include NERVE INJURY, DAMAGE TO ONE OR MORE VITAL ORGANS, EVEN MAJOR DISABILITY OR DEATH. Although major complications of anesthesia are fortunately rare in healthy people, some types of health problems increase the risk of such occurrences, so it is important that you fully and accurately complete the health history questionnaire. Prior to your surgery, an anesthesiologist will talk with you. During this preoperative visit, you are encouraged to discuss to your satisfaction the anesthesia recommended for you, the possible alternatives, as well as a more detailed discussion of the risks of the anesthesia mentioned above. Please ask as many questions as you feel necessary in order to assist you in making an informed decision. Your signature in this page gives consent to the administration of anesthesia by your anesthesiologist. Furthermore, your consent includes your acknowledgment that risk of complications always exists as a result of anesthetic management.