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APASS Patient Questionnaire

At birth was the patient:
Has the patient ever had general anesthesia (been put to sleep)?
Did the patient have any problems with being put to sleep or waking up from the anesthesia?
Have you ever been told the patient was difficult to intubate?
Has the patient ever had a high fever with anesthesia? (ex. malignant hyperthermia)
Does the patient have any problems opening the mouth or moving the head/neck?
Does the patient see any speciality doctors (cardiology, pulmonary, neurology, endocrinology, etc)?
Has the patient ever had any of the following conditions? Check all that apply.
Implantable Metal Devices
Check if the patient uses:

PATIENT RECENT ILLNESS


1. Has the patient had a cold or upper respiratory tract infection in the last 14 days?
2. Has the patient had a stomach virus in the last 7 days?
3. Has the patient had COVID-19, bronchitis/bronchiolitis, croup, pneumonia or flu in the last 4-6 weeks?
4. Has the patient taken steroids (Cortisone, Prednisone, Prednisolone, Orapred) in the last 6 weeks? (Do not include daily inhaled steroids)
5. Has the patient been seen in an Emergency Room in the last 2 months?
6. Has the patient been admitted to the hospital in the last 3 months?

FAMILY HISTORY (Patient blood relatives)


1. Is there a family history of serious complications or unexpected death related to anesthesia?
patient is adopted or in DHR custody/foster care
2. Is there a family history of dangerously high fevers associated with anesthesia (Malignant Hyperthermia)?
patient is adopted or in DHR custody/foster care
3.Is there a family history of sensitivity to anesthesia medications (Pseudocholinesterase Deficiency)?
patient is adopted or in DHR custody/foster care
4. Is there a family history of muscle disease (Muscular Dystrophy, etc.)?
patient is adopted or in DHR custody/foster care
5. Is there a family history of bleeding disorders (Hemophilia, Von Willebrand Disease, etc)?
patient is adopted or in DHR custody/foster care
6. Is there a family history of blood disorders (Sickle Cell Trait, Sickle Cell Anemia, Thalassemia, etc)?
patient is adopted or in DHR custody/foster care
7. Has anyone living in the patient’s house had COVID-19 in the last 4 weeks (or are they awaiting COVID-19 test results)?

IF the patient is in DHR custody, please provide DHR contact information.