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: *

Home Phone Number: *

Parent/Legal Guardian:

Work Phone Number:

Cell Phone Number 1:

Cell Phone Number 2

Additional Contact Number

Parent's E-mail Address

(Patient's) Primary Care Physician

Physician Office Number:

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

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

Will the Patient spend the night in the hospital after the surgery/procedure?

Yes No Don't Know None

Patient's Birth Hospital

Patient's Birth Weight

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

Was the patient born early?

Yes No Don't Know None

If so, how many months/week early?

Patient's Birth complications:

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

Yes No Don't Know None

If so, what is the name of the hospital where the general anesthesia was administrated?

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:

Have any of the patient's blood relatives ever had anesthesia complications?

Yes No Don't Know None

(Malignant hyperthermia, problems with Anectine, pseudocholinesterase deficiency, etc:) If so, please explain:

Do any of the patient's blood relatives have a bleeding disease or blood disorder?

Yes No Don't Know None

(Hemophilia, Von Willebrand's Disease, Sickle Cell Disease/Trait, Thalassemia, etc:) If so, please explain:

Do any of the patient's blood relatives have a muscle disease?

Yes No Don't Know None

(Muscular Dystrophy, Spinal Muscular Atrophy, Friedreich's Ataxia, etc.:) If so, please explain

Does the patient have any implantable metallic devices?

If Other, please specify:

If so, Where?

Has the patient been sick in the last week (cold, stomach virus, etc.)?

Yes No Don't Know None

If so, what symptoms and when did they start?

Has the patient had bronchitis, croup, pneumonia or flu in the last 4-6 weeks?

Yes No Don't Know None

If so, what was the diagnosis and when?

Has the patient had mononucleosis within the last 2 months?

Yes No Don't Know None

Has the patient had to take steroids in the last 2 months?

Yes No Don't Know None

If so, when and why?

Has the patient been to the emergency department or been admitted to the hospital in the last 3 months?

Yes No Don't Know None

If so, where, when and for what reasons?

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

Yes No Don't Know None

Does the patient have any loose, broken or capped teeth?

Yes No Don't Know None

Does the patient wear glasses or contact lenses?

Yes No Don't Know None

Does the patient have piercings other than the ears?

Yes No Don't Know None

If the patient is female has she started her menstrual cycle?

Yes No Don't Know None

If so, list the date of the last period

If the patient is female and has started her mentstrual cycle, is there any chance that she is now pregnant or has been pregnant in last 3 months?

Yes No Don't Know None

Has the patient had a blood transfusion or received any type of blood product in the last 3 months?

Yes No Don't Know None

Does the patient use tobacco products alcohol or addictive/recreational drugs?

Yes No Don't Know None

Are there any cultural/religious beliefs that would change the plan of care at CHS (no blood product)?

Yes No Don't Know None

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.

Abnormal Sickle Cell Trait Airway Problems Anemia Arthritis Asthma/Wheezing/Reactive Airway Disease (RAD) Birth Defects Cerebral Palsy (CP) CPAP/BiPAP Croup (Recurrent) Cystic Fibrosis (CF) Diabetes Glaucoma Heart Disease or Condition Heart Murmur Hemophilia Hepatitis High/Low (BP) Blood Pressure History of Organ Transplantation Home Oxygen Home Ventilator (vent) Jaundice Kidney Disease Laryngomalacia Liver Disease Malignant Hyperthermia Rheumatic Fever Seizures Sickle Cell Disease Sleep Apnea Stomach (acid) reflux Subglottic Stenosis Syndromes Thalassemia Thyroid Disease Tracheostomy (trach) Tuberculosis (TB) Von Willebrand's Disease Hydrocephalus Autism Spina Bifda Developmental Delay

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

Full Name of person completing questionnaire

Choose Your Relationship to the Patient (For questions about the online form please call 205-638-6235)

If Other, please specify:

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