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

If Patient is less than 12 years old, please use pediatric preop evaluation form

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 any ALLERGIES: __________________________________________________________________

List all the medications that you now take:

     
     
     
     


List any other medications that you have taken in the last year:
_____________________________________________________________________________________

List all of the operations that you have 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: __________________________________________________________________

DO YOU NOW HAVE: (circle correct answer)      Comments
A cough or cold ..........................................
NO
YES
  __________________________________
Glaucoma ..................................................
NO
YES
  __________________________________
Chipped/loose teeth, caps,
dentures, crowns, or bridgework ...................
NO
YES
  __________________________________
Do you use tobacco now? ..........................
NO
YES
  __________________________________
Have you used tobacco in the past? ...........
NO
YES
  __________________________________
If yes, chewing, cigars, pipe, cigarettes  (circle one)  
     Cigarettes ____________ Packs per day for ______________ years
     **If you no longer smoke, how long ago did you quit? ________________________

Do you ever use alcohol
(wine, beer or hard liquor)?
NO
YES
  What Kind? _______________________
If yes, daily, weekly, or rarely? (circle one)      

Do you ever get high on drugs?
(marijuana, cocaine, heroine, speed etc)?
NO
YES
  What Kind? _______________________
If yes, daily, weekly, or rarely? (circle one)      

HAVE YOU EVER HAD? (circle correct answer) 
Stoke .........................................................
NO
YES
  __________________________________
Epilepsy or seizures ....................................
NO
YES
  __________________________________
Weakness of an arm or a leg ........................
NO
YES
  __________________________________
Numbness in arms, hands, legs or feet ..........
NO
YES
  __________________________________
Muscle disease ...........................................
NO
YES
  __________________________________
High or low blood pressure ............................
NO
YES
  __________________________________
Heart murmur..............................................
NO
YES
  __________________________________
Chest pain or pressure or angina ...................
NO
YES
  __________________________________
Heart attack ................................................
NO
YES
  __________________________________
An irregular heart beat ..................................
NO
YES
  __________________________________
Abnormal electrocardiogram (ECG) ...............
NO
YES
  __________________________________
Shortness of breath that wakes you up ..........
NO
YES
  __________________________________
Problems breathing when you lie flat ..............
NO
YES
  __________________________________
Chest x-ray that was not normal ....................
NO
YES
  __________________________________
Bronchitis or frequent cough .........................
NO
YES
  __________________________________
Asthma or wheezing ....................................
NO
YES
  __________________________________
Rheumatoid arthritis .....................................
NO
YES
  __________________________________
Excessive or easy bleeding ..........................
NO
YES
  __________________________________
Anemia (low blood count) .............................
NO
YES
  __________________________________
Blood transfusion .........................................
NO
YES
  __________________________________
Sickle cell disease .......................................
NO
YES
  __________________________________
Heartburn or hiatal hernia ..............................
NO
YES
  __________________________________
Yellow jaundice or hepatitis ..........................
NO
YES
  __________________________________
Exposure to tuberculosis, hepatitis or AIDS ...
NO
YES
  __________________________________
Thyroid problems .........................................
NO
YES
  __________________________________
Diabetes or high sugar .................................
NO
YES
  __________________________________
Kidney problems .........................................
NO
YES
  __________________________________
Cancer .......................................................
NO
YES
  __________________________________
Family member with nerve or
muscle disease ...........................................
NO
YES
  __________________________________
Parent, brother or sister who had a heart attack before age 50 ....................................
NO
YES
  __________________________________

Women: Could you be or are you pregnant?     NO    YES __________________________________

First day of last period: _______/_______/_______

Is there anything else about your health that you think we should know to help us to care for you?

    NO   YES     If yes, please explain:
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________


___________________________________________________________________________________
Patient's Signature Date

___________________________________________________________________________________
Physician's Signature Date

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