Pre-Anaesthesia Questionnaire

Please either fill in the following fillable PDF forms (for a child or adult) that you can print and sign and send back to us or use the online form below to submit the questionnaire directly. Thank you

Child pre-anaesthesia questionnaire form (pdf)

Adult pre-anaesthesia questionnaire form (pdf)

Quick Online Pre-Anaesthesia Questionnaire

Date [mm/dd/yyyy]*
MM slash DD slash YYYY
Email*
Is this for a child or an adult?*
- Child
- Adult
Pre-Anaesthesia Questionnaire (Child)
Child's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Does your child have any health problems or concerns presently?*
- Yes
- No
- Not Sure
Please explain health concerns in detail.*
Has there been ANY change in your child's general health in the past year?*
- Yes
- No
- Not Sure
When did your child last visit their family physician? (month and year)*
Has your child ever been in hospital for treatment?*
- Yes
- No
- Not Sure
When, where and why were they in the hospital?*
Has your child ever had general anaesthesia or surgery?*
- Yes
- No
- Not Sure
When, where and why did they have general anaesthesia or surgery?*
Were there any problems with the anaesthesia?*
Have you or any of your family relatives had problems with anaesthesia?*
- Yes
- No
- Not Sure
Please explain the problems with anaesthesia?*
Were any tests done?*
Does your child have a drug allergy?*
- Yes
- No
- Not Sure
What drug?*
What year?*
What happened? Check all that apply*
- Rash
- Breathing problems/wheezing
- Swelling
- Other
Other - what else happened with the drug allergy*
Does your child have any other allergies (e.g. latex)?*
- Yes
- No
- Not Sure
What other allergies do they have?*
Does your child take ANY medications right now (including puffers)? Please list:*
- Yes
- No
- Not Sure
Please list all medications with dose*
Does your child take ANY non-prescription remedies (including herbal remedies)?*
- Yes
- No
- Not Sure
Name of any non-prescription remedies*
Has your child had a cortisone (steroid) type drug orally in the past year?*
- Yes
- No
- Not Sure
When was the cortisone type drug taken?*
For how long was the cortisone type drug taken?*
Has your child taken any medicine for a long time in the past?*
- Yes
- No
- Not Sure
Name of medicine taken for a long time*
Reason for taking medicine for a long time.*
Has your child had aspirin or aspirin containing compounds (ASA, Bufferin, Anacin, 222) within the last week?*
- Yes
- No
- Not Sure
Does your child or anyone in the family have a bleeding problem?*
- Yes
- No
- Not Sure
Has your child been exposed to any infectious diseases in the past month?*
- Yes
- No
- Not Sure
Does your child have any difficulty breathing while sleeping at home?*
- Yes
- No
- Not Sure
Does your child have or ever had any of the following? Please check all that apply.*
- Heart Murmur
- Congenital heart disease
- Chest pain or angina
- Heart pacemaker/defibrillator
- Irregular heart beat/arrhythmia
- Damaged/abnormal heart valves
- Rheumatic fever
- Liver disease / Jaundice
- Hepatitis
- Blood / Coagulation disorders
- Anemia (including sickle cell)
- Thalassemia
- Kidney disease
- Adrenal gland problems
- Diabetes
- HIV, AIDS
- Asthma
- Cystic fibrosis / Tuberculosis
- Croup
- Other lung diseases
- Cancer / Chemotherapy
- Fainting spells, dizziness
- Thyroid problems
- Glaucoma or vision problems
- Muscular dystrophy
- Arthritis
- Bone, joint or muscle problems
- Stomach ulcers/Acid reflux
- Sleep apnea
- Pseudocholinesterase deficiency
- Malignant hyperthermia
- Epilepsy/ Seizures/convulsions
- Cerebral palsy
- Down’s syndrome
- Autism
- Mentally disabled
- None of the above
Does your child have any difficulty breathing through their nose?*
- Yes
- No
- Not Sure
Does your child have any nose bleeds?*
- Yes
- No
- Not Sure
How many nose bleeds per week?*
Does your child have problems running around and playing freely?*
- Yes
- No
- Not Sure
Does your child get short of breath very easily?*
- Yes
- No
- Not Sure
Does your child turn a blue colour and/or faint when trying to run or play?*
- Yes
- No
- Not Sure
Does your child have any problems opening his/her mouth wide?*
- Yes
- No
- Not Sure
Does your child have any problems moving his/her neck freely?*
- Yes
- No
- Not Sure
Has your child ever had surgery and/or radiation treatment for a tumour or cancer?*
- Yes
- No
- Not Sure
Does your child smoke?*
- Yes
- No
- Not Sure
If your child is of child bearing age, is she pregnant?*
- Yes
- No
- Not Sure
Does your child have any loose teeth (especially front teeth)?*
- Yes
- No
- Not Sure
Does your child have ANY disease, condition or problem not mentioned so far?*
- Yes
- No
- Not Sure
How much does your child weigh?*
Any additional comments?
What is your relationship to the child?*
- Parent
- Guardian
- Patient
Informed Consent for Dental Treatment under Sedation/General Anaesthesia*
I agree to the consent for dental treatment under sedation/general anaesthesia written below.
Please read. THIS FORM MUST BE SIGNED BEFORE THE PROCEDURE

I understand that the following has been provided to me so that I may be informed of the choices and risks involved with having dental procedures performed under anaesthesia. It is my understanding that this information has been presented to enable me to make well-informed decisions concerning my child's treatment, not to make me anxious. My choices for anaesthesia are local anaesthesia alone, or in combination with intravenous deep sedation or general anaesthesia.

I have been informed that aside from drowsiness, the most frequent side effects of any anaesthetic occur in less than 15% of patients and include but are not limited to nausea, vomiting, sore throat, general muscle soreness and inflammation with tenderness and/or bruising around the intravenous site. Since anaesthesia may cause drowsiness and incoordination that may be enhanced by the use of alcohol or drugs, it is understood that they are to be avoided until completely recovered from the effects of anaesthesia and prescription medicines: I understand that the operation of any vehicle or any hazardous device/machine, or making any important decisions is to be avoided for at least 24 hours or until completely recovered from the effects of anaesthesia. Parents are advised of the necessity for direct supervision of children for 24 hours following their anaesthesia.

I understand that on rare occasions there are anaesthesia related complications which include but are not limited to pain, hematoma, numbness, infection, swelling, bleeding, skin discolouration, allergic reaction, tooth damage, and fluctuations in heart rhythm and/or blood pressure. I further understand and accept the extremely remote possibility that complications may arise which may require hospitalization, and/or result in brain damage or death. I have been made aware that local anaesthesia carries with it the least amount of risk and deep sedation/general anaesthesia the most. However, local anaesthesia alone is not appropriate for every patient or procedure.

I understand that anesthetics and other medicines may be harmful to an unborn child and may cause birth defects or spontaneous abortion. Recognizing these risks, I accept full responsibility for informing Dr. Gizzarelli of a suspected or confirmed pregnancy with the understanding that this will necessitate the postponement of anaesthesia. For similar reasons, I understand that I must inform Dr. Gizzarelli if my child is a nursing mother.

I hereby authorize and request Dr. Gizzarelli or his staff to contact persons on my behalf and obtain any previous or current medical records/information when needed to properly assess my child's health status prior to anaesthesia.

I hereby authorize and request Dr. Gizzarelli to perform anaesthesia as previously explained to me, and any other procedure deemed necessary or advisable as a corollary to the planned anaesthesia. I consent, authorize and request the administration of such anaesthetic(s) by any route that is deemed suitable by Dr. Gizzarelli. It is the understanding of the undersigned that Dr. Gizzarelli will have full charge of the administration and maintenance of the anaesthetic.

I have been fully advised and completely understand the alternatives of conscious sedation, deep sedation and general anaesthesia, and accept all possible risks and consequences. I acknowledge receipt of and completely understand both pre-operative and post-operative anaesthesia instructions. It has been explained to me and I accept that there is no warranty or guarantee as to any result and/or cure. I have had the opportunity to ask questions about my child's anaesthetic and I am satisfied with the information provided to me.
Signature*
Date*
MM slash DD slash YYYY
Pre-Anaesthesia Questionnaire (Adult)
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Do you have any health problems or concerns presently?*
- Yes
- No
- Not Sure
Please explain any health concerns*
Has there been ANY change in general health in the past year?*
- Yes
- No
- Not Sure
When did you last have a complete physical exam? (month and year)*
How often do you see your family doctor or specialist? Every...*
Have you ever been in the hospital for treatment?*
- Yes
- No
- Not Sure
When, where and why were you in the hospital?*
Have you ever had general anaesthesia or surgery?*
- Yes
- No
- Not Sure
When, where and why did you have general anaesthesia?*
Were there any problems with the anaesthesia?*
Have you or any of your family or relatives had problems with anaesthesia?*
- Yes
- No
- Not Sure
Please explain any problems with anaesthesia*
Were any tests done?*
Do you have a drug allergy?*
- Yes
- No
- Not Sure
What drug and what year?*
Please check any and all symptoms you had*
- Rash
- Breathing problems/wheezing
- Swelling
- Other
What else happened with the drug allergy*
Do you have any other allergies (such as latex)?*
Do you take ANY medications right now (including puffers and birth control pills)*
- Yes
- No
- Not Sure
Please list your medications and dose*
Do you take ANY non-prescription remedies (including herbal remedies)?*
- Yes
- No
- Not Sure
Please list all non-prescription remedies you take*
Have you taken a cortisone (steroid) type drug orally in the past year?*
- Yes
- No
- Not Sure
When did you take it?*
How long were you taking it for?*
Do you or any of your relatives have a bleeding problem?*
- Yes
- No
- Not Sure
Do you have or have had any difficulty breathing through your nose?*
- Yes
- No
- Not Sure
Do you have any nose bleeds?*
- Yes
- No
- Not Sure
How many nose bleeds per week?*
Do you have any difficulty breathing while sleeping at home?*
- Yes
- No
- Not Sure
Can you walk up 2 flights of stairs or 2 city blocks quickly without resting?*
- Yes
- No
- Not Sure
Do you have or ever had any of the following? Please check all that apply.*
- Heart Murmur
- Heart Attack
- Chest pain or angina
- Shortness of breath lying down
- Swollen ankles
- Heart pacemaker/defibrillator
- Irregular heart beat/arrhythmia
- High blood pressure
- Congenital heart disease
- Damaged/abnormal heart valves
- Rheumatic fever
- Kidney disease
- HIV, AIDS or STD
- Malignant hyperthermia
- Pseudocholinesterase deficiency
- Cancer / Chemotherapy
- Sleep apnea
- Asthma
- Emphysema / Bronchitis
- Cystic fibrosis / Tuberculosis
- Epilepsy/ Seizures/convulsions
- Stroke
- Fainting spells, dizziness
- Diabetes
- Thyroid problems
- Adrenal gland problems
- Hepatitis
- Liver disease / Jaundice
- Anemia (including sickle cell)
- Blood disorders / transfusions
- Bleeding (coagulation) disorders
- Stomach ulcers/Acid reflux
- Bone, joint or muscle problems
- Artificial joints - hips, knees
- Arthritis
- Depression / anxiety
- Glaucoma or vision problems
- Mentally disabled
- Cerebral palsy
- Autism or Down’s syndrome
- For Women: Are you pregnant?
- For Women: Are you a nursing mother?
- For Women: Any problems with menstruation?
- None of the above
Do you ever have episodes of blurred vision or black spots, or experience weakness or paralysis on one side of your body, arms, legs or face?*
- Yes
- No
- Not Sure
Do you have any problems opening your mouth wide or moving your neck fully?*
- Yes
- No
- Not Sure
Have you ever had surgery, radiation or chemotherapy treatment for a tumour or cancer?*
- Yes
- No
- Not Sure
Do you smoke?*
- Yes
- No
- Not Sure
How much do you smoke?*
Do you drink more than 5 alcoholic beverages per week?*
- Yes
- No
- Not Sure
How many alcoholic beverages consumed per week?*
Do you have a history of alcoholism or drug dependence?*
- Yes
- No
- Not Sure
Have you taken any recreational drugs in the past year such as marijuana, LSD, PCP, cocaine, crack, crystal meth, codeine, oxycodone or other drugs?*
- Yes
- No
- Not Sure
Please specify type(s)*
Do you have ANY disease, condition or problem not listed above?*
- Yes
- No
- Not Sure
Please explain*
How much do you weigh?*
What is your height?*
Any additional comments?
Informed Consent for Dental Treatment under Sedation/General Anaesthesia*
I agree to the consent for dental treatment under sedation/general anaesthesia written below.
Please read. THIS FORM MUST BE SIGNED BEFORE THE PROCEDURE

I understand that the following has been provided to me so that I may be informed of the choices and risks involved with having dental procedures performed under anaesthesia. It is my understanding that this information has been presented to enable me to make well-informed decisions concerning my treatment, not to make me anxious. My choices for anaesthesia are local anaesthesia alone, or in combination with conscious intravenous anaesthesia, or deep sedation/general anaesthesia.

I have been informed that aside from drowsiness, the most frequent side effects of any anaesthetic occur in less than 15% of patients and include but are not limited to nausea, vomiting, sore throat, general muscle soreness and inflammation with tenderness and/or bruising around the intravenous site. Since anaesthesia may cause drowsiness and incoordination that may be enhanced by use of alcohol or drugs, I have been advised to abstain from their use until completely recovered from the effects of anaesthesia and prescription medicines. I understand that I should not operate any vehicle, any hazardous device/machine, or make any important decisions for at least 24 hours or until completely recovered from the effects of anaesthesia. Parents are advised of the necessity for direct parental supervision of children for 24 hours following their anaesthesia.

I understand that on rare occasions there are anaesthesia related complications that include but are not limited to pain, hematoma, numbness, infection, swelling, bleeding, skin discolouration, allergic reaction, tooth damage, and fluctuations in heart rhythm and/or blood pressure. I further understand and accept the extremely remote possibility that complications may arise which may require hospitalization, and/or result in brain damage or death. I have been made aware that local anaesthesia carries with it the least amount of risk and deep sedation/general anaesthesia the most. However, local anaesthesia alone is not appropriate for every patient or procedure.

I understand that anaesthetics and other medicines may be harmful to an unborn child and may cause birth defects or spontaneous abortion. Recognizing these risks, I accept full responsibility for informing Dr. Gizzarelli of a suspected or confirmed pregnancy with the understanding that this will necessitate the postponement of the anaesthetic. For similar reasons, I understand that I must inform Dr. Gizzarelli if I am a nursing mother.

I hereby authorize and request Dr. Gizzarelli or his staff to contact persons on my behalf and obtain any previous or current medical records/information in order to properly assess my health status prior to anaesthesia.

I hereby authorize and request Dr. Gizzarelli to perform anaesthesia as previously explained to me, and any other procedure deemed necessary or advisable as a corollary to the planned anaesthesia. I consent, authorize and request the administration of such anaesthetic(s) by any route that is deemed suitable by Dr. Gizzarelli. It is the understanding of the undersigned that Dr. Gizzarelli will have full charge of the administration and maintenance of the anaesthesia.

I have been fully advised and completely understand the alternatives to conscious sedation, deep sedation and general anaesthesia, and accept all possible risks and consequences. I acknowledge receipt of and completely understand both pre-operative and post-operative anaesthesia instructions. It has been explained to me and I accept that there is no warranty or guarantee as to any result and/or cure. I have had the opportunity to ask questions about my anaesthetic and I am satisfied with the information provided to me.
Signature*
Date*
MM slash DD slash YYYY

4444 Drummond Rd.,

289-271-0021

Pre-Anaesthesia Questionnaire

Quick Online Pre-Anaesthesia Questionnaire

Pre-Anaesthesia Questionnaire (Child)

Pre-Anaesthesia Questionnaire (Adult)