Patient Forms

Patient Health Questionnaire

Please complete the entire questionnaire by answering all questions to the best of your ability. Click on "Yes" or "No" as appropriate. If a question does not apply to you or you don't know how to answer, leave the question blank or click on the "N/A / Don't Know" button.

Name
AgeGender
HeightWeight
Type of Surgery
(i.e. Body Part)
Date of SurgeryTime of Surgery
(if known)
Physician

All Patients

Have you had previous Surgery?
If so, what type of surgery?
Have you or any blood relative ever had any problems with anesthesia?
Do you have allergies of any kind, including latex?
If so, please list:
Do you have dentures, plates or bridges, loose, cracked, chipped, capped, or bonded teeth?
Can you open your mouth fully?
Do you wear contact lenses?
Have you ever been diagnosed with sleep apnea or do you snore heavily?
Have you ever had an alcohol problem?
Do you smoke cigarettes?
Are you an ex-smoker?
Do you have asthma?
Have you had a chest X-ray or EKG in the past 12 months?
Have you ever had heart or lung surgery?
Have you ever had a heart attack?
Do you ever have chest pains, angina, chest heaviness or tightness?
Do you have high blood pressure?
Have you ever been told that you have mitral valve prolapse?
Do you have an irregular heart beat?
Have you ever had a heart pacemaker?
Have you or a blood relative ever had a serious blood clotting problem?
Have you ever had a blood transfusion?
Have you ever had a seizure or convulsion?
Have you ever had a stroke or been paralyzed?
Have you ever had numbness or tingling in your arms or legs?
Have you ever had hepatitis, yellow jaundice or liver disease?
Do you have a hiatal hernia/acid reflux?
Have you ever had problems with your kidneys or kidney failure?
Do you have diabetes?
If so, do you take insulin or pills?
Do you take thyroid medication?
Are you HIV positive?
Have you ever been treated for cancer?
Do you suspect you may be pregnant?
Do you use birth control pills?
Daily Medications (prescriptions and non-prescriptions) Dose and Frequency:

Pediatric Patients

Did you experience a preterm birth?
If so, are there any lasting effects?
Does your child have breath-holding spells or apnea?
Does your child have any developmental delays or syndromes?
Does your child have any other problems that have not been mentioned?

By clicking on the submit button I certify that all information on this form is correct and true to the best of my knowledge.