Pre Surgical Screening Questionnaire - Interior Health

Summary
ASA Classification:
Old chart available and reviewed:
Recent consults attached:
Relevant previous investigations attached:
Results reviewed:
Abnormal results notified to physician:
Clinic visit required:
Follow up required:
Details:
Critical care bed required and booked:
Has the surgeon explained the procedure and possible complications to your satisfaction?
Confirmed with the:
1
2
Nursing:
Pharmacy:
Anesthesia:
3
Patient Committee of Person Representative Legal Guardian of person under 19.
Name: Signature: Date:
Yes
Yes
No
No
N/A
Name: last / first / middle
Surgeon
Procedure
Sex
History from: Phone or in person (please circle) Primary Language:
Ht: Wt: BMI ( kg /cm 2 ) HR: BP: O 2 Sat:
(Actual or estimated - please circle)
Previous Anesthetics:
Procedure
Problems/Complications:
Family history of problems with anesthesia:
Family history of Malignant Hyperthermia:
Dental: crowns, caps, bridges, dentures, chipped or loose teeth.
Details:
Pre Surgical Screening Questionnaire
DOB
Contact telephone number:
None
Approximate Date
Procedure
Yes
Approximate Date
No
Don’t
Know
Completed: Date
Signature:
Medication:
None
Include herbal and over the counter medication
Drug
Dose
Frequency
Drug
Dose
Frequency
Final Telephone Contact:
Final Instructions given:
Date:
Bowel prep:
Skin prep:
Fasting:
Medication:
Allergies:
Drug or product
None
(Specify true allergy or sensitivity)
Reaction Drug or product Reaction
Contact info for arrival time:
Any equipment to be brought in:
Yes
No
Any change in health status?
Yes
No
Ready for Surgery?
RN Name:
Signature:
Latex Allergy:
Anticoagulants: eg ticlid, comumadin, plavix, heparin, ASA, NSAIDS?
Any chemotherapeutic agents in the last three months?
Habits:
Yes
Yes
Yes
No
No
No
Smoker:
Yes
No
If so, how many?
Drinks alcohol every day?
Yes
No
If so, how much?
Substance abuse problems or street drug use?
Yes
No
If so, what?
826011 Jun 05

Systems Review
Nursing Issues
Cardiac Symptoms:
None
Angina or myocardial infarct.
If so, how often or when?
Heart valve problems or artificial heart valve.
Palpitations or arrhythmia
Pacemaker or automatic defibrillator.
History of angioplasty or heart surgery.
Treatment for hypertension.
-Difficult to treat, multiple meds or complications.
Congestive heart failure or peripheral edema.
Exercise tolerance.
Details:
Respiratory Symptoms:
None
Asthma, emphysema or COPD
Is it worse recently or any recent steroid use or ICU admission?
History of stopping breathing while asleep.
Diagnosed sleep apnea.
Unable to climb two flights of stairs.
Details:
Neuro Symptoms:
None
History of stroke or TIA
Within the last six months?
History of seizures. If so when was the last?
Muscular dystrophy, myotonia, ALS, multiple sclerosis, myasthenia, paraplegia.
Details:
Other Symptoms and History:
None
Diabetes. If so, controlled with diet, diabetes or insulin?
Renal failure.
Rheumatoid arthritis.
Pain, stiffness or arthritis in jaw or neck.
Excessive bleeding or bruising.
History of DVT or Pulmonary embolus.
Anemia or other blood problem.
Thyroid problems
Hepatitis or jaundice
HIV / AIDS
Heartburn / hiatus hernia
Any previous admission to ICU.
Previous confusion after anesthesia.
Medic alert bracelet. If so, what does it say?
In a life threatening situation, would patient refuse blood?
Details:
Medical problem summary:
Yes No N/A
General
Skin integrity:
Braden Scale Yes
Urinary tract:
Bowels:
Diet:
Behavioural or emotional issues:
Cognitive Behaviour:
confused alert / orientated
Problems with mobility? none cane walker wheelchair crutch prosthesis
Last menstrual period:
Glasses / contacts:
Other prosthesis:
Details of above.
Current living situation
Live alone:
Yes
Type of dwelling:(specify)
Stairs: number inside:-
Are you a principle caregiver?
Hearing aids:
No
outside:-
Yes
Could patient be pregnant at time of surgery?
No concerns
Lives with.
No
Support Services
No concerns
Do you currently have someone that helps you?
Yes
No
N/A
What services are currently in place?
None
Mental health worker
Long term/residential care. Where?
Community Care
Community OT/OP
Palliative Care
Community social worker
Home 02,
Handi dart.
Adult day care.
Home makers
Other
Details:
Plan for Discharge
What are your plans once you are discharged?
Will there be someone to pick you up from the hospital?
Day care patients: will there be someone to stay with you or who can call for the first 24 hours?
Any Social Services or Community Health Services required post op?
Yes
Yes
Yes
Details
N/A
No
No
No
Wishes to discuss anesthesia prior to the day of surgery.
Flag as anesthetic challenge on OR slate.
Add extra time for anesthesia issues.
Yes
Yes
Yes
No
No
No
Infection Issues:
None
Have you been a patient in another hospital for > 48 hours in the last 3 months?
Patient admitted from another facility? If so which:
MRSA form required:
Yes
No
Yes
No