APASS Questionnaire Birmingham, Alabama (AL)

Surgeon:

Date of Surgery:

Procedure:

(Patient's Legal Name) Last Name: *

First Name: *

Middle Initial:

Nickname:

(Patient's) Date of Birth: *

Parent/Legal Guardian: *

Parent/Legal Guardian Contact Phone Number(s) (including area code): *

(Patient's) Primary Care Provider (PCP)

Provider (PCP) Office Number:

Primary Care Provider (PCP) City:

Patient's current MEDICATIONS: (including nebulizer, aerosol, herbal, over-the-counter):

Patient's ALLERGIES: (Ex. none, foods, drugs or latex):

Patient's Birth Hospital

Patient's Birth Weight

How long did the patient stay in the hospital at birth?

At birth was the patient:

Full Term (greater than or equal to 37 weeks) Premature (less than 37 weeks) twin or multiple birth vent at birth oxygen at birth apnea monitor at birth

Patient's Birth complications:

Has the patient ever had general anesthesia (been put to sleep)?

Yes No Don't Know None

Surgeries:

Did the patient have any problems with being put to sleep or waking up from the anesthesia?

Yes No Don't Know None

(Difficulty passing the endotrachael tube, high fever, rash, breathing problem, excessive nausea, etc) If so, explain:

Does the patient have any problems opening the mouth or moving the head/neck?

Yes No Don't Know None

If YES, please explain mouth, neck or head problems.

Does the patient see any speciality doctors (cardiology, pulmonary, neurology, endocrinology, etc)?

Yes No Don't Know None

If so, please list specialty doctor's names

Has the patient ever had any of the following conditions? Check all that apply.

Acid Reflux Airway Condition Asthma Autism Bleeding Disorder Blood Disorder Bronchopulmonary Dysplasia (BPD) Cancer Cerebral Palsy (CP) Cochlear Implant CPAP/BiPAP Diabetes Down Syndrome Feeding Tube Heart Condition Heart Murmur High Blood Pressure History of Organ Transplantation Home Oxygen Home Ventilator (vent) Immune Condition Kidney Condition Liver Condition MRSA Muscle Disease Paralysis Seizures Sickle Cell Anemia Sickle Cell Trait Sleep Apnea Thyroid Condition Wheezing

If the patient has any existing conditions not in the list, please list here

1. Has the patient had a cold or upper respiratory tract infection in the last 14 days? *

No Yes

2. Has the patient had a stomach virus in the last 7 days? *

No Yes

3. Has the patient had bronchitis/bronchiolitis, croup, pneumonia or flu in the last 6 weeks? *

No Yes

4. Has the patient been treated with steroids (prednisone, prednisolone, orapred) in the last 6 weeks? *

No Yes

5. Has the patient been seen in an Emergency Room in the last 2 months? *

No Yes

6. Has the patient been admitted to the hospital in the last 3 months? *

No Yes

If YES to questions #1-6, please explain:

1. Is there a family history of serious complications or unexpected death related to anesthesia? *

No Yes

2. Is there a family history of dangerously high fevers associated with anesthesia (Malignant Hyperthermia)? *

No Yes

3.Is there a family history of sensitivity to anesthesia medications (Pseudocholinesterase Deficiency)? *

No Yes

4. Is there a family history of muscle disease (Muscular Dystrophy, etc.)? *

No Yes

5. Is there a family history of bleeding disorders (Hemophilia, Von Willebrand Disease, etc)? *

No Yes

6. Is there a family history of blood disorders (Sickle Cell Trait, Sickle Cell Anemia, Thalassemia, etc)? *

No Yes

If YES for questions #1-6, please explain:

DHR County:

Caseworker's Name:

Caseworker's Contact phone #s (include area code):

Full Name of person completing questionnaire

Authentication *

* Required

PATIENT RECENT ILLNESS

FAMILY HISTORY (Patient blood relatives)

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

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