Please Note: This preoperative evaluation form is similar to the one you will be asked to fill out prior to surgery. It is provided here for your convenience. You may print it, fill it out and bring it to your anesthesiologist to expedite your child's preoperative evaluation.

Old Pueblo Anesthesia
5700 E. Pima Suite E, Tucson, AZ 85712
(520) 324-2030 Phone (520) 324-2619 Fax

Name:______________________________________________Date of Surgery:____________________

Hospital:_____________________________  Surgeon:________________________________________

Patient's Age:_________ Sex:_______ Height: ___________ inches/cm   Weight: ___________ lbs/kg

List all the medications that your child now takes:

     
     
     
     


List any other medications that your child has taken in the last year:
_____________________________________________________________________________________

List all of the operations that your child has ever had:

Operation: Date: Type of Anesthesia/
sleep medicine:		 Any problems with anesthesia/sleep medicine:
_______________ ___________ _______________________ ______________________
_______________ ___________ _______________________ ______________________
_______________ ___________ _______________________ ______________________
_______________ ___________ _______________________ ______________________


Has any blood relative ever had problems with anesthesia/sleep medicine?       NO      YES
If yes, please explain: __________________________________________________________________

HAVE YOUR CHILD EVER HAD? (circle correct answer)

Epilepsy or seizures ....................................
NO
YES
  __________________________________
Blue or fainting spells ...................................
NO
YES
  __________________________________
Muscular dystophry .....................................
NO
YES
  __________________________________
Heart murmur..............................................
NO
YES
  __________________________________
Heart disease (e.g. failure, irregular beats ......
NO
YES
  __________________________________
Pneumonia ..................................................
NO
YES
  __________________________________
Chronic or frequent cough .............................
NO
YES
  __________________________________
Asthma or wheezing ....................................
NO
YES
  __________________________________
Rheumatoid arthritis .....................................
NO
YES
  __________________________________
Easy bleeding (e.g. nose bleeds) ..................
NO
YES
  __________________________________
Anemia (low blood count) .............................
NO
YES
  __________________________________
Blood transfusion .........................................
NO
YES
  __________________________________
Sickle cell or other blood disease ..................
NO
YES
  __________________________________
Reflux or hiatal hernia ...................................
NO
YES
  __________________________________
Live disease like hepatitis .............................
NO
YES
  __________________________________
Exposure to TB, hepatitis or AIDS .................
NO
YES
  __________________________________
Diabetes or sugar problems ..........................
NO
YES
  __________________________________
Kidney problems .........................................
NO
YES
  __________________________________
Cancer .......................................................
NO
YES
  __________________________________
Family member with nerve or
muscle disease ...........................................
NO
YES
  __________________________________

A cough or cold within the last month ..........
NO
YES
  __________________________________

Any chipped or loose teeth ...........................

NO

YES
  
__________________________________

Dentures, caps, crowns or bridgework ...........

NO

YES
  
__________________________________

Metal or plastic parts
(e.g. metal rods, heart valves) .......................

NO

YES
  
__________________________________

Was your child born more than
3 weeks early? ............................................

NO

YES
 __________________________________

Is your child growing and gaining
weight normally? .........................................

NO

YES
 __________________________________
If no, please explain: ___________________________________________________________________

Does your child have
spastic or floppy muscles? ...........................

NO

YES
  
__________________________________
If yes, please explain: __________________________________________________________________

Does your child have special problems with his/her sight, hearing or ability to talk? ..........

NO

YES
  
__________________________________
If yes, please explain: __________________________________________________________________

Are your child's immunizations
(shots) up to date? ......................................

NO

YES
  
__________________________________

Has your child been with anyone in the past month with chicken pox, measles, mumps, rubella, or spinal meningitis? ........................

 

NO



YES
__________________________________
If yes, which infection(s)? _______________________________________________________________

Do you have any other concerns
about your child? .........................................

NO

YES
 __________________________________
If yes, what are they? __________________________________________________________________

Pediatrician:

Name: ___________________________________________________________

Phone Number: ___________________________________________________

Child's other doctors (e.g. heart doctor, breathing doctor, kidney doctor):
Name: Name:
Specialty: Specialty:
Phone Number: (____) _____________________ Phone Number: (____) _____________________


___________________________________________________________________________________
Parent's Signature Date

___________________________________________________________________________________
Physician's Signature Date

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