APASS Questionnaire Birmingham, Alabama (AL)

Full Name of person completing questionnaire

Surgeon:

Date of Surgery:

Procedure:

PATIENT'S LEGAL NAME (First Name): *

Middle Name:

Last Name: *

Preferred Name:

(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

How far along in the pregnancy was the mother when the baby was born? (month/weeks/days)

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 discharged home on oxygen discharged home on monitor

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

If YES, then please explain:

Have you ever been told the patient was difficult to intubate?

Yes No Don't Know None

If YES, then please explain.

Has the patient ever had a high fever with anesthesia? (ex. malignant hyperthermia)

Yes No Don't Know None

If YES, then please 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 YES, please list specialty doctor's names

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

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

Implantable Metal Devices

Baclofen Pump Bone Anchored Hearing Aid (BAHA) Cochlear Implant Pacemaker Vagal Nerve Stimulator (VNS) Other None

If Other, please specify:

Check if the patient uses:

Alcohol Tobacco Products Recreational Drugs

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 COVID-19, bronchitis/bronchiolitis, croup, pneumonia or flu in the last 4-6 weeks? *

No Yes

4. Has the patient taken steroids (Cortisone, Prednisone, Prednisolone, Orapred) in the last 6 weeks? (Do not include daily inhaled steroids) *

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

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)? *

No Yes

If YES for questions #1-7, please explain:

DHR County:

Caseworker's Name:

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

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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