Toggle navigation
Locations and Directions
Locations Map
Emergency Department
Pediatric Practices
Programs and Services
Patients and Visitors
Visitation
Planning Your Visit
Online Pre-Registration
Patient Billing Information
Patient Name Change Request Form
Financial Assistance
Request Medical Records
Request Medical Records (PDF)-Spanish
Immunization Schedule
Immunization Catch-up Schedule
Find a Doctor
Ways to Help
Support Children's
Volunteer
Quick Links
About Children's
For Healthcare Professionals
Careers
Newsroom
Español
205-638-9100
About Children's
For Healthcare Professionals
Careers
Newsroom
Español
205-638-9100
Locations and Directions
Locations Map
Emergency Department
Pediatric Practices
Programs and Services
Patients and Visitors
Visitation
Planning Your Visit
Online Pre-Registration
Patient Billing Information
Patient Name Change Request Form
Financial Assistance
Request Medical Records
Request Medical Records (PDF)-Spanish
Immunization Schedule
Immunization Catch-up Schedule
Find a Doctor
Ways to Help
Support Children's
Volunteer
Home
Email Forms Manager
APASS Patient Questionnaire
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:
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)?
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?
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?
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)
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?
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)?
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.
Has the patient ever had any of the following conditions? Check all that apply.
Acid Reflux
Airway Condition
Anxiety
Asthma
Autism
Bleeding Disorder
Blood Disorder
Bronchopulmonary Dysplasia (BPD)
Cancer
Cerebral Palsy (CP)
CPAP/BiPAP
Depression
Developmental Delay
Diabetes
Down Syndrome
Feeding Tube
Heart Condition
Heart Murmur
Hemophilia
High Blood Pressure
History of Organ Transplantation
Home Apnea Monitor
Home Oxygen
Home Oxygen Saturation Monitor
Home Ventilator (vent)
Immune Condition
Kidney Condition
Liver Condition
MRSA
Muscle Disease
Paralysis
Seizures
Sickle Cell Anemia
Sickle Cell Trait
Sleep Apnea
Suicide Attempt
Thalassemia
Thyroid Condition
TRACH
Tuberculosis (TB)
Wheezing
If the patient has any existing conditions not in the list, please list here
Implantable Metal Devices
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:
Check if the patient uses:
Alcohol
Tobacco Products
Recreational Drugs
PATIENT RECENT ILLNESS
1. Has the patient had a cold or upper respiratory tract infection in the last 14 days?
*
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?
*
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?
*
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)
*
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?
*
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?
*
6. Has the patient been admitted to the hospital in the last 3 months?
No
Yes
If YES to questions #1-6, please explain:
FAMILY HISTORY (Patient blood relatives)
1. Is there a family history of serious complications or unexpected death related to anesthesia?
*
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)?
*
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)?
*
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.)?
*
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)?
*
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)?
*
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)?
*
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:
IF the patient is in DHR custody, please provide DHR contact information.
DHR County:
Caseworker's Name:
Caseworker's Contact phone #s (include area code):
Authentication
*
* Required
Submit