PRE−ANAESTHETIC QUESTIONNAIRE
 
Last Name:*
First Name:*
 
Cell Phone: Alternate:
Address:
City: Province:
Postal Code: Date of Birth:
Health Card #:*
Email:*
 
Primary Dental Insurance (if applicable)
None   Group/Private   Community Services  
if you selected Group / Private Insurance above, please fill out this section:
Group Name:
Plan Holder Name: (Last) (First)
Relationship with Plan Holder: SELF      Spouse      Common Law      Dependant
Plan Holder's D.O.B Employer of Plan Holder
Plan / Group Number ID / Certificate Number
       
Secondary Dental Insurance (if applicable)
None   Group/Private   Community Services  
if you selected Group / Private Insurance above, please fill out this section:
Group Name:
Plan Holder Name: (Last) (First)
Relationship with Plan Holder: SELF      Spouse      Common Law      Dependant
Plan Holder's D.O.B Employer of Plan Holder
Plan / Group Number ID / Certificate Number
       
Do you have a responsible adult to accompany you home and stay with you for 24 hours after Day Surgery?
Yes No     
*If you answered NO, you must make these arrangements or your surgery will be cancelled*
 
What is Your Weight? lbs kgs
What is Your Height? ft cm
Do you have a Latex Allergy? Yes No
Do you have any other allergies? Yes No If yes, please list:
 
Do you take any medications?       
 Yes No  If yes, list all medications below.
All prescriptions, inhalers, patches, drops, vitamins, herbs and over the counter medications.
Medication Dose and how often Medication Dose and how often
     
Do you smoke cigarettes? Yes No If yes, a day
Are you an ex−smoker? Yes No    If yes, how many years did you smoke?  
When did you stop? (YYYY/MM/DD)
Do you Vape? Yes No If yes, how much?
Do you use Marijuana? Yes No If yes, a day
Do you use any illegal drugs? Yes No    If yes: Type: Amount:
How often:
 
Do you drink alcohol? Yes No    If yes, how many per day?
Per week?
 
Do you need to take antibiotics before surgery? Yes No    List:
 
Have you ever had an operation before? Type of Anaesthesia
Year Operation Local:
Numbing the site of surgery		 Regional:
Nerve Block / Sprinal Epidural		 General:
Went to sleep
 
Have you ever had a problem with anaesthesia? Yes No
Has anyone in your family had problems with anaesthesia? Yes No
Has anyone in your family had or been diagnosed with Malignant Hyperthermia? Yes No
Do you have any of the following? (check all that apply): Loose, chipped or capped teeth Dentures
Braces, or bridgework Hearing aids
Contact lens Glasses
Are you Diabetic?     Yes No       If yes, controlled by:    Diet    Pills    Insulin
Do you have any of the following?
Yes No If yes, please indicate:		 Thyroid problems Cancer
Kidney problems
     Describe:
Liver problems / jaundice
     Describe:
Hiatal hernia / reflux or heart burn
Stomach ulcers  
Bowel problems, Crohns, colitis
Do you have a C−PAP machine at home? If so, bring the machine with you to the hospital on the day of your surgery. If you do not use C−PAP, please answer the following questions:
Do you have sleep apnea? Yes No
Do you snore loudly? (Louder than talking or loud enough to be heard through closed doors?) Yes No
Do you often feel tired, fatigued, or sleepy during daytime? Yes No
Has anyone observed you stop breathing during sleep? Yes No
Is your neck measurement greater than 16 inches in women? 17 inches in men? Yes No
Do you have or are you being treated for high blood pressure? Yes No
Have you ever had problems with your heart?
Yes No If yes, please indicate:		 Heart attack Cardiac surgery
Heart murmur Irregular heart beat
Chest pain / angina High cholesterol

Have you ever had problems with your breathing?
Yes No If yes, please indicate:

Problems walking up stairs Persistent cough
Bronchitis or tuberculosis Asthma / wheezing
Shortness of breath  
Have you ever had any of the following problems?
Yes No If yes, please indicate: 		History of stroke Convulsions / epilepsy
Head injury Headaches / migraines
Fainting Arthritis
Numbness / tingling in hands and feet
Trouble opening your mouth
Have you ever had severe muscle weakness or paralysis of any part of your body? Yes No
Have you ever tested positive for HIV or hepatitis? Yes No
Have you ever had any bleeding problems?     Yes No     Details?
Have you ever had a blood transfusion?     Yes No    If yes,

Date: (YYYY/MM/DD)
Details?

Would you accept blood or blood products if needed? Yes No Details?
Have you ever been treated for a "blood clot" or DVT? Yes No Details?
If you are a female: When was your last period?
Is there a possibility that you might be pregnant and / or have been within the last 3 months? Yes No
Are you breastfeeding? Yes No
For children under the age of 16: Are all immunizations up to date? Yes No
Does your child have developmental delays or learning disabilities? Yes No
If yes, please describe:
   
Patient’s / Caregiver’s Signature: Date: (YYYY/MM/DD)

Citadel Privacy & Consent

ACKNOWLEDGEMENT

Citadel Privacy Statement

Having read and understood the Privacy Statement for Patients, I hereby consent to the collection, use and disclosure of my personal information as presented in the statement, subject to the restriction identified below.
Please check the appropriate box

NO RESTRICTIONS

Consent to disclose any collected information to Insurance Companies or other health care professionals as may be directly involved in your dental or medical care.

 

RESTRICTED ACCESS

My personal information shall not be provided to the following individuals or organizations:

 

RESTRICTED INFORMATION

My personal information disclosed shall not include my following personal information:



 

AUTHORIZATION (if applicable)

I authorize release; to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named provider. I hereby assign my benefits, payable from claims submitted electronically to continue in effect until the undersigned revokes the same.

  Check here to accept