HOWARD COUNTY

GENERAL HOSPITAL
JOHNS HOPKINS MEDICINE

HC1001 5-1

PRE-ANESTHESIA ASSESSMENT FORM

Please call 410-884-4693 for questions regarding this form.
Procedure: ❑Left ❑Right
Name you would preferred to be called:
Age Height Weight BMI Date of Surgery
List of all previous surgeries: Medications (prescribed medications, Food and drug allergies/reactions:
over the counter medications):

Premed:
❑ Taking Beta blockers

❑ Takin Blood thinners Time: ❑ Latex allergy

Check Do you now have or have you ever had a history of:
Check Do you now have or have you ever had a history of:
Cardiovascular Disease
❑ Chest Pain/Tightness/Pressure/ Heart Attack Blood Disorder
❑ Irregular Heart Beat ❑ Abnormal bleeding tendency or taking blood thinners
❑ Pacemaker/Defibrillator Brand: ❑ Sickle cell disease or trait
❑ Problem with circulation ❑ History of blood transfusions
❑ Blood clot in legs or lungs ❑ Religious or other objections to blood transfusion
❑ High blood pressure ❑ HIV positive/AIDS
❑ Other ❑ Eye Disorder/Glaucoma/Retinal detachment
Resirator Diseasep y ❑ Ear Disorder/"Ringing" in ears/Hearing loss
❑ Smoking packs per day; Quit ❑ Cancer/chemotherapy/radiation therapy
❑ Asthma If yes, specify
❑ Emphysema/bronchitis
❑ Shortness of breath at rest ❑ Psychiatric disorder
❑ Upper respiratory infection (cold) within 2 weeks If yes, specify
❑ Sleep apnea ❑ Use CPAP
❑ Other illness or disease
Neurological Disorder Ifyes, specify
❑ Stroke or mini-stroke (T.I.A.) For women
❑ Seizures ❑ Could you be pregnant?
❑ Back or neck problems First day of last menses
❑ Phsical restrictions/limitationsy ❑ Post menopause/hysterectomy
❑ Forgetfulness, memory loss, confusion
Anesthesia Related Information
❑ Multiple sclerosis/muscular dystrophy
❑ Anesthesia within one year
❑ Nerve/spinal cord injury
❑ Neuropathy ❑ History of difficult intubation
❑ Any objection to spinal/epidural anesthesia
❑ Diabetes . ❑ Taking insulin ❑ Insulin pump ❑ Adverse reaction to anesthesia
❑ Relative with Malignant Hyperthermia
❑ Thyroid Problem
❑ Nausea or vomiting after anesthesia
❑ Kidney/Bladder/Prostate Disorder ❑ Are you aware of the risk of eating or drinking the day of
If yes, specify your anesthesia
❑ Inability to urinate after anesthesia Because drugs may interact adversely with
0 Dialysis : Schedule anesthesia, please indicate the following:
Gastro-Intestinal Disease ❑ History of regular alcohol use or within 24 hours
❑ Liver disease (jaundice, hepatitis) ❑ Use of steroids/cortisone in the past year
❑ Hiatal hernia/reflux/heartburn ❑ History of "street drugs" use or within 30 days
❑ Other
❑ Loose or capped teeth or dentures in place

If form completed by patient: Date Time Patient Signature

MEDICAL RECORD
10015-1 3/06 (Rev 11/20/12) Page 1 of 2
 HOWARD COUNTY
GENERAL HOSPITAL
JOHNS HOPKINS MEDICINE

HC10015-1

PRE-ANESTHESIA ASSESSMENT FORM

To be completed by staff only

NPO
T BP
P R 02 Sat

FBS

WBC Hct Plts

Na cl Glucose BUN

K C02 Cr

INR PT PTT

UPT/SPT: ❑ Neg ❑ Pos Date

LFT's: Ca:
CXR
Date
EKG
Date
Echo
Date
N 4,4% u (
Stress Test N
r T �
Date
U

PHYSICIAN ONLY
The risks, benefits, and alternatives of GA, Reg.
and Loc/Sed have been Intubation Assessment
discussed.
I II III IV
The plan is: ❑ GA ❑ Regional ❑ IV Sedation ❑ Dentures ❑ Caps/Crowns
❑ TIVA ❑ MAC
❑ Overbite ❑ Loose teeth
and/or
ROM: ❑ Full ❑ Limited ❑ None
❑ Lungs: clear to auscultation OR
Date Time Signature
Physician/CRNA ❑ Heart: regular rhythm with no murmurs OR

❑ H&P reviewed, patient assessed; fit for planned anesthesia.

ASA 1 2 3 4 5 6 E

10015-1 3/06 (Rev. 7/17/12) Page 2 of 2

MEDICAL RECORD