Children's South Surgery Preop Questionnaire | Children's of Alabama

In this section

Child's Name

Date of Birth

Surgeon's Name

Today's Date

Date of Surgery

Child's Approximate Weight

Medications (prescribed, over the counter and herbal) being taken at this time:

Drug Allergies

It is extremely important that someone from our Anesthesia Department speak with you the day before surgery. Please list the numbers where you can be reached before 1:00 PM

Your Name

Home Phone

Work Phone

Cell Phone

Beeper

May we leave a detailed message at any of these numbers?

Yes

No

Was your child premature?

Yes

No

If yes, by how many weeks?

Did they require further treatment due to prematurity?

Yes

No

If yes, please explain:

Does your child now experience any complications resulting from prematurity?

Yes

No

If yes, please explain:

Has your child had surgery or been hospitalized for any reason before?

Yes

No

Please list surgical procedure or reason for hospitalization, when, and at what hospital:

Has a blood relative had a serious complication other than nausea with anesthesia?

Yes

No

Does any blood relative have muscular dystrophy or hemophilia?

Yes

No

Are your child’s immunizations up to date?

Yes

No

Has your child been exposed to a contagious disease (Chicken Pox, Strep, intestinal infection, pink eye, lice, ringworm, etc.) within the last three weeks?

Yes

No

For Syndromes, please list the types:

Have you ever needed a nebulizer or inhaler?

Yes

No

If yes, when was the last time it was used, and how often it is needed?

If you have Obstructive Sleep Apnea, how long does it last? (5-10 seconds, more than 10 seconds?)

If your child has seen a doctor for any of the conditions above, please list the doctor’s name and the last time they were seen: