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.

Click here to download the pre-anaesthesia form (pdf)

Online Pre-Anaesthesia Questionnaire-2024

All information will be kept confidential.

Please answer all questions.
Patient Information
Sex*
- Male
- Female
Title*
- Mr.
- Mrs.
- Ms.
- Miss
- Dr.
- Child/Youth
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Weight*
NOTE: if you weigh over 250lbs – please call us for clearance first (your weight may make it difficult to safely evacuate you in case of an emergency!
Weight units*
- lbs.
- kg.
Height*
Height units*
- m-cm
- ft-in
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Business Phone*
Cell Phone*
Email*
Who has the legal authority to sign the CONSENT on pages 10 and 11 (if the patient cannot): Note: this individual must be reachable at the time of anesthesia! If informed consent cannot be obtained, the surgery cannot proceed.
Legal Authority Name:*
Legal Authority Email:*
Is any other applicable custodian (i.e. parent) informed and in agreement?*
- Yes
- No
Please Explain:*
Companion Information
Companion Name*
First Last
Companion Phone*
Companion relationship to patient*
Medical Care Information
Family Physician*
Physician Phone*
Physician Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient's OHIP number and version code:*
Patient's OHIP Expiry:*
Medical Questions
1. Does the patient have any health problems or concerns presently (including a recent – in the last two weeks - colds, flu, cough, runny nose – if yes, please notify the office and speak to the anesthesia provider)?*
- Yes
- No
- Unsure
Please explain:*
Does the patient suffer from:
High blood pressure*
- Yes
- No
- Unsure
Heart disease*
- Yes
- No
- Unsure
Chest pain, angina, MI*
- Yes
- No
- Unsure
Heart failure*
- Yes
- No
- Unsure
Shortness of breath*
- Yes
- No
- Unsure
Pacemaker*
- Yes
- No
- Unsure
Irregular heart beat*
- Yes
- No
- Unsure
Abnormal heart valves*
- Yes
- No
- Unsure
Heart murmur*
- Yes
- No
- Unsure
Liver disease*
- Yes
- No
- Unsure
Hepatitis*
- Yes
- No
- Unsure
Daily alcohol drinking*
- Yes
- No
- Unsure
Alcohol dependence*
- Yes
- No
- Unsure
Blood clotting disorders*
- Yes
- No
- Unsure
Anemia*
- Yes
- No
- Unsure
Thalassemia*
- Yes
- No
- Unsure
Adrenal gland problems*
- Yes
- No
- Unsure
Diabetes, thyroid*
- Yes
- No
- Unsure
HIV, AIDS*
- Yes
- No
- Unsure
Asthma*
- Yes
- No
- Unsure
Tuberculosis*
- Yes
- No
- Unsure
Cystic fibrosis*
- Yes
- No
- Unsure
Bronchitis, COPD*
- Yes
- No
- Unsure
Emphysema*
- Yes
- No
- Unsure
Epilepsy, seizures*
- Yes
- No
- Unsure
Fainting spells*
- Yes
- No
- Unsure
Stroke, TIA*
- Yes
- No
- Unsure
Weakness, paralysis*
- Yes
- No
- Unsure
Glaucoma*
- Yes
- No
- Unsure
Neuromuscular condition*
- Yes
- No
- Unsure
Arthritis*
- Yes
- No
- Unsure
Artificial joints*
- Yes
- No
- Unsure
Gastric reflux, heartburn*
- Yes
- No
- Unsure
Stomach ulcers, bleeding*
- Yes
- No
- Unsure
Developmental Delay*
- Yes
- No
- Unsure
Behavioral Issues*
- Yes
- No
- Unsure
Any other (not mentioned above):*
- Yes
- No
- Unsure
Please Explain:*
2. Does anyone in the patient’s household currently have symptoms of COVID?*
- Yes
- No
- Unsure
3. Did the patient have COVID in the last 2 months?*
- Yes
- No
- Unsure
4. Has there been ANY change in general health in the past year?*
- Yes
- No
- Unsure
5. Has the patient ever been in hospital?*
- Yes
- No
- Unsure
When, where and why?*
6. Has the patient ever had general anesthesia or surgery?*
- Yes
- No
- Unsure
When, where and why?*
7. Were there any problems with the anesthesia?*
- Yes
- No
- Unsure
8. Have the patient’s family relatives had problems during or after an anesthesia (i.e. malignant hyperthermia, pseudocholinesterase etc.)?*
- Yes
- No
- Unsure
Please explain.*
9. Does the patient have a drug allergy?*
- Yes
- No
- Unsure
What drug?*
What happened?*
- Rash
- Breathing problems
- Swelling
- Other allergic reaction
- Nothing happened
10. Does the patient have any other allergies?*
- Yes
- No
- Unsure
If yes, what type?*
11. Does the patient take ANY medications currently (including puffers, birth-control pills)?*
- Yes
- No
- Unsure
Please list ALL medications including doses and times usually taken:*
12. Does the patient use or take ANY non-prescription remedies (including herbal remedies) right now?*
- Yes
- No
- Unsure
Name*
13. Has the patient had a cortisone (steroid) type drug orally, injected or inhaled in the past year?*
- Yes
- No
- Unsure
When?*
For how long?*
14. Has the patient taken any medicine for a long duration in the past that is not listed above?*
- Yes
- No
- Unsure
Name*
Reason*
15. Has the patient had aspirin or aspirin-containing compounds (ASA, Bufferin, Anacin, 222) within the last week?*
- Yes
- No
- Unsure
16. Does the patient or does anyone in the family have a bleeding problem?*
- Yes
- No
- Unsure
17. Has the patient ever had an excessive amount of bleeding following surgery such as tooth extraction?*
- Yes
- No
- Unsure
18. Has the patient been exposed to any infectious diseases in the past month?*
- Yes
- No
- Unsure
If so, which?*
19. Does the patient have any difficulty breathing while sleeping at home?*
- Yes
- No
- Unsure
Is the patient known to have ‘obstructive sleep apnea’?*
- Yes
- No
- Unsure
20. Does the patient have any difficulty breathing through the nose?*
- Yes
- No
- Unsure
21. Does the patient have nose bleeds?*
- Yes
- No
- Unsure
If so, how many per week?*
Which side?*
22. Does the patient have problems walking (2 city blocks), running or climbing stairs (2 flights)?*
- Yes
- No
- Unsure
23. Does the patient get short of breath easily?*
- Yes
- No
- Unsure
24. Does the patient ever turn blue in colour and/or faint when trying to run or climb stairs?*
- Yes
- No
- Unsure
25. Does the patient have any problems opening his/her mouth wide?*
- Yes
- No
- Unsure
26. Does the patient have any problems moving his/her neck freely?*
- Yes
- No
- Unsure
27. Has the patient ever had surgery and/or radiation treatment for a tumor or cancer?*
- Yes
- No
- Unsure
28. Does the patient smoke?*
- Yes
- No
- Unsure
If yes, how much?*
If the patient quit smoking, when was this (year and month)?*
29. Has the patient used recreational drugs (crack, cocaine or other drugs) in the last 6 months?*
- Yes
- No
- Unsure
30. Is there any possibility that the (female) patient is pregnant?*
- Yes
- No
- Unsure
31. Is the (female) patient nursing?*
- Yes
- No
- Unsure
32. Does the patient have any loose teeth (especially front teeth) or capped teeth?*
- Yes
- No
- Unsure
Where?*
33. Does the patient have ANY disease, condition or problem not mentioned so far?*
- Yes
- No
- Unsure
Please explain other disease/condition/problem not mentioned:*
34. Thrombosis Risk Factor Assessment: Please check all pertinent factors*
- Age 41 to 60 years
- Age 61 to 70 years
- Age over 70 years
- History of Deep Vein Thrombosis/PE
- Family history of Deep Vein Thrombosis
- Obesity (>20% of ideal body weight)
- Leg edema, ulcers, stasis
- Malignancy
- Pregnancy or postpartum (< 1 month)
- Inflammatory bowel disease
- Hormone therapy
- None of the Above
35. Nausea/Vomiting Risk Factor Assessment: Please check all pertin*
- Female
- Nonsmoker
- History of :postoperative nausea/vomiting (PONV), motion sickness, family history of PONV
- None of the above
36. Obstructive Sleep Apnea Risk Factor Assessment: Please check all pertinent factors*
- You snore loudly (heard through closed doors)
- You often feel tired, fatigued or sleepy during daytime
- Someone has observed you stop breathing during your sleep
- You have high blood pressure
- You are over 50 years old
- You are male
- None of the Above
Consent Section
Informed Consent for Dental Treatment under Sedation/General Anaesthesia*
I agree to the consent for dental treatment under sedation/general anaesthesia written below.
I understand that the following has been provided to me so that I may be informed of the choices and risks involved with having a procedure performed under anaesthesia. It is my understanding that this information has been presented to enable me to make well-informed decisions concerning my or my child’s treatment, not to make me anxious.

I have been informed that aside from drowsiness, the most frequent side-effects of any anaesthetic include, but are not limited to, nausea, vomiting, sore throat, hoarseness, general muscle soreness and inflammation with tenderness and/or bruising around the intravenous site.

Depending on the procedure performed, some degree of post-operative pain is to be expected. Since anaesthesia may cause drowsiness and in coordination that may be enhanced by the use of alcohol or drugs, it is understood that (other than usual prescription medications or medication prescriptions provided for the relief of post-operative discomfort) they are to be avoided until completely recovered from the effects of anaesthesia. I understand that the operation of any vehicle or any hazardous device/machine, or the making of 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 parental 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, urinary
retention, visual loss, aspiration, negative pressure pulmonary edema, organ failure, malignant hyperthermia, skin discoloration, allergic reaction, oral dental 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, result in brain damage, failure to recover, coma from anesthesia or death. I have been made aware that local anaesthesia carries with it the least amount of risk and sedation/general anaesthesia the most. However, local anaesthesia alone may not be appropriate for some patients or procedures.

I understand that anesthetics and other medicines may be harmful to an unborn child and could result in spontaneous abortion or cause birth defects. Recognizing these risks, I accept full responsibility for informing the anaesthetist 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 the anaesthetist if I am (or my child is) a nursing mother.

Some authorities believe that surgery after COVID should be delayed for approximately 2 months. This is because the rate of complications may significantly increase in patients with recent symptomatic or asymptomatic COVID infections. Please consider this when scheduling your surgery.

Nerve, muscle and tissue injury, while overall rare, can occur under anesthesia and factors that may increase this risk include pre-existing nerve damage (for example due to diabetes) and a large body mass. In many cases no clear reason is apparent (i.e. the injury occurred even though best care was taken to avoid factors such as stretch or compression). The prognosis for full (or at least substantial) recovery is generally good but some patients are unfortunately left with a permanent injury.

I hereby authorize and request Anaesthesia Professionals 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 the anaesthetist 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 the anaesthetist. It is the understanding of the undersigned that
the anaesthetist will have full charge of the administration and maintenance of the anaesthetic, and that this is an independent function from the surgery or dental work.

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 / my child’s anaesthetic and I am satisfied with the information provided to me.

I hereby acknowledge that I am a resident in the province of Ontario and I agree that the resolution of any and all disputes arising from or in connection with my care by the anaesthetist (as well as his agents and/or delegates) shall be governed by and construed in accordance with the laws of the Province of Ontario and that the Courts of the Province of Ontario shall have the exclusive jurisdiction.

I hereby acknowledge that I am a resident in the province of Ontario and I agree that the resolution of any and all disputes arising from or in connection with my care by the anaesthetist (as well as his agents and/or delegates) shall be governed by and construed in accordance with the laws of the Province of Ontario and that the Courts of the Province of Ontario shall have the exclusive jurisdiction.
A note about awareness under general anaesthesia: The chance for a patient to be awake (in pain and paralyzed, unable to communicate) under general anaesthesia is extremely remote and most reported cases involve patients that undergo high-risk hospital-based surgical procedures coupled with the use of paralyzing medications (cardiac surgery, emergency operations, caesarean sections etc.). The type of surgery and the anaesthetic medications for office-based general anaesthesia tend to be very different from the above-mentioned cases (for example, paralyzing medications are generally not used). While some hospitals (for selected cases) use a tool to monitor brain activity that might help to detect awareness, it is not clear that these tools make a difference to patient safety, and these monitors, particularly for office-based anaesthesia, are not routinely used. A note about children and anesthesia: Anesthetic and sedative drugs are widely used to help ensure the safety, health, and comfort of children undergoing surgery. There is evidence from studies which suggests the benefits of these agents should be considered in the context of their potential to cause harmful outcomes, such as adverse neurobehavioural effects. However, these studies have limitations that prevent experts from drawing conclusions on whether the harmful effects were due to the anesthesia or to other factors, such as surgery, hospitalization, or pre-existing conditions. In the absence of conclusive evidence, it would be unethical to withhold sedation and anesthesia when necessary. It is important to recognize that current anesthetics and sedatives are necessary for infants and children who require surgery or other painful and stressful procedures. (Extract from Smart Tots IARS Consensus Statement on the Use of Anesthetics and Sedatives in Children, Dec 2012) www.smarttots.org/resources/consensus.html A note about older adults and anesthesia: Elderly patients, especially when already slightly impaired at baseline (i.e. dementia) are at risk of further decrease in their function after anesthesia (including confusion, inattention and memory problems). Together with their frailty the acute confusion that is possible after anesthesia can make the management of those patients challenging and we strongly advise to have adequate support (at least two physically fit individuals) come for the appointment to safely escort the patient home and stay with him/her.
Signature
Date*
MM slash DD slash YYYY
Signature*
Print Name*
First
Witness Signature
Witness Date*
MM slash DD slash YYYY
Witness Signature*
Witness Print Name*
First

4444 Drummond Rd.,

289-271-0021

Pre-Anaesthesia Questionnaire

Online Pre-Anaesthesia Questionnaire-2024

Patient Information

Companion Information

Medical Care Information

Medical Questions

Consent Section

Signature

Witness Signature