Pre-Anesthesia Questionnaire

Please complete this form in its entirety to help us deliver the safest anesthesia care to you.

Name (First & Last)

Date of Birth

Age

Phone Number

Email Address

Date of Your Procedure

What procedure are you having?

Gender

Male Female

Allergies

Weight

Pounds

Primary Care Physician/Specialists

***Due to potential fetal risk, we may perform a urine pregnancy test before your procedure if you are between the ages of 15 and 55, have not had a hysterectomy, tubal ligation, or reached menopause.

Do you currently have, or have you ever had a medical history of the following Cardiovascular conditions?

High Blood Pressure

NO YES

Heart Failure

NO YES

Abnormal Heart Rhythm

NO YES

Heart Murmur

NO YES

Heart Attack, Coronary Artery Disease, or Chest Pain/Angina

NO YES

Pacemaker or Defibrillator

NO YES

Do you currently have, or have you ever had a medical history of the following Respiratory conditions?

Please reschedule your appointment until at least 2 weeks after symptoms have resolved (runny nose, congestion, cough, fever, etc.). Your airway is sensitive up to 4-6 weeks after an cold or upper/lower respiratory infection. By not disclosing or waiting at least 2 weeks since your last symptom to have anesthesia puts you at unnecessary risks.

I Understand

What is the reason you cannot walk upstairs without stopping?

Do you currently have, or have you ever had a medical history of the following Gastrointestinal conditions?

Acid Reflux or GERD

NO YES

Hiatal Hernia

NO YES

Hepatitis

NO YES

Do you currently have, or have you ever had a medical history of the following Neurological conditions?

Stroke/CVA/TIA

NO YES

Seizures or Epilepsy

NO YES

Alzheimer's or Dementia

NO YES

Do you currently have, or have you ever had a medical history of the following Musculoskeletal, Hematologic, Endocrine, or Genitourinary conditions?

Diabetes

NO YES

Kidney Disease

NO YES

Thyroid Disease

NO Hyperthyroidism Hypothyroidism

Blood Clots (DVT/PE)

NO YES

List all other medical conditions not previously mentioned here

Please answer honestly to the following Social History questions to ensure your safety.

Answers are confidential and HIPAA protected.

Do you smoke or vape?

NO YES

What do you smoke?

Cigarettes/Nicotine

Marijuana

How long have you smoked?

Smoking Guidelines Acknowledgement

Smoking or vaping cigarettes, cigars, and/or marijuana during the time leading up to my procedure has been proven to increase risks of negative outcomes during anesthesia-care (heart attack, cardiac failure, respiratory failure, increased and excessive bleeding, and abnormal blood sugar levels, etc.).

Due to the increased risk of complications, MAC Anesthesia reserves the right to cancel your case on the day of service if you smoke cigarettes, cigars, or vape within 24 hours and THC within 30 hours prior to the day of your scheduled procedure.

I understand that adhering to the above the smoking guidelines is the safest way to put me to sleep. If my procedure is cancelled because the Smoking Guidelines were not followed, I understand that I will be responsible for anesthesia payment.

I Understand

Do you consume alcohol?

NO YES

What type of alcohol and how often?

Do you currently use or have a history of illicit drug use? ex.) Cocaine, Meth, Heroin, etc.

NO YES

What type of drug and last used?

Do you currently take any of the following substances for weight loss: Ozempic/Wegovy (semegulitide) or Mounjaro/Zepbound (tirzepatide)?

NO YES

These medication causes food that you eat to be processed slower than normal. This puts you at risk for food still being in your stomach and going into your lungs (aspiration) under anesthesia. To keep you safe, DO NOT take this medication for 7 days BEFORE your procedure date.

My last dose of this medication will be longer than 7 days before my procedure.

List all Medications you currently take

List all Surgical Procedures you have had

NPO (Nothing by Mouth) Guidelines

With your safety as our top priority, the safest and best practice is to have nothing to eat or drink 8 hours prior to your procedure start time. However, for patients who feel they cannot fast for 8 hours, the following guidelines are the current recommendations and will be followed with absolute vigilance.

Please note: Amounts of food or liquid taken by mouth are irrelevant and are not considered when the NPO Guidelines have been broken.

8 Hours- Any solid food containing fat.
6 Hours- Any solid food that is fat free. Also, any non-clear liquid or liquid containing fats and/or acids. (ex., coffee with cream, orange Juice, smoothies).
2 Hours- Clear Liquids. (ex., black coffee, water, Gatorade).

I understand that avoiding food and liquids for 8 hours prior to my procedure is the safest way to put me to sleep. If my procedure is cancelled because the NPO Guidelines were not followed, I will be responsible for anesthesia payment.

I Understand

Recovery Companion Guidelines

A key factor in keeping you safe begins with ensuring you have an adequate companion for your postoperative recovery period. An adequate companion will meet the following criteria:

A responsible adult over the age of 18.
Holds a current Driver’s License.
Able to transfer patient to and from car/wheelchair/bathroom.
Able to stay with patient until the morning immediately following procedure day.
Verbalizes comfort caring for a patient in a post-anesthesia-discharge state.

If you cannot provide a companion that meets these criteria on the day of service, or your companion is deemed inadequate by our anesthesia providers, your procedure may be postponed or cancelled.

*Driving services (Taxi, Uber, Lyft, etc.) are not acceptable recovery companions.

I understand that I must provide a recovery companion to transport me from the office after my procedure and care for me during the post-anesthesia recovery period. If my procedure is cancelled because the Recovery Companion Guidelines were not followed, I will be responsible for anesthesia payment.

I Understand

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