Citadel Surgery - BW Health Questionnaire

PRIMARY DENTAL INSURANCE (if applicable)

None

Group / Private

Community Services

Group Name

Last Name

First Name

Relationship with Plan Holder:

Self

Spouse

Common Law

Dependant

Plan Holders Date of Birth

Employer of Plan Holder

Plan / Group Number

ID / Certificate Number

SECONDARY DENTAL INSURANCE (if applicable)

None

Group / Private

Community Services

Group Name

Last Name

First Name

Relationship with Plan Holder:

Self

Spouse

Common Law

Dependant

Plan Holders Date of Birth

Employer of Plan Holder

Plan / Group Number

ID / Certificate Number

OPERATION HISTORY

What operations have you had in the past? Please include where and when (approximate year) you had the operation.

Procedure

Year

Hospital

10.

ANESTHETIC HISTORY

Yes / No / Not Sure

Comments

1. Have you had severe nausea (feeling sick to your stomach) or severe vomiting (throwing up) after surgery?

Yes

Not Sure

2. Have you been told that you have a ’difficult airway’ or that placing a breathing tube in your airway is difficult?

Yes

Not Sure

3. Have you or a family member (related by blood) had a serious problem after receiving an anesthetic?

Check all that apply:

Yes

Not Sure

Malignant hyperthermia (uncommon life−threatening reaction to anesthesia with high temperatures and muscle rigidity)

Pseudocholinesterase deficiency (sensitivity to the muscle relaxant Succinylcholine which can be used during general anesthesia)

Other (specify in comments):

DO YOU TAKE ANY MEDICATIONS?

Yes

If YES, list all of the medications that you take (including herbal medication, vitamins, prescription and non−prescription drugs).

Medication

Dose

When You Take It

10.

11.

12.

13.

14.

15.

DO YOU HAVE ANY ALLERGIES?

Yes

If YES, please list all of your allergies and your reactions.

Allergic to

Reaction

BREATHING

Yes / No / Not Sure

Comments

1. Do you need to stop while climbing one flight of stairs or walking two blocks on a flat surface due to shortness of breath?

Yes

Not Sure

2. Do you have a problem lying flat for over 30 minutes because of difficulty breathing?

Yes

Not Sure

3. Have you smoked tobacco of any kind or vaped in the past?

Yes

If YES, please indicate which?

Cigarettes

Cigars

Pipes

Vaping

Other:

Have you quit smoking?

Yes

If YES, When?

4. Have you been told that you have emphysema or chronic obstructive pulmonary disease (COPD)?

Yes

Not Sure

5. Do you have asthma?

Yes

Not Sure

6. If you use inhalers, do you need to take your rescue medication (e.g. Ventolin/Salbutamol) more than twice per week?

Yes

Not Sure

7. In the past 5 years have you gone to the emergency room, been admitted to hospital, or prescribed a steroid (e.g. prednisone or hydrocortisone) for your breathing?

Yes

Not Sure

8. Do you use oxygen at home to help you breathe?

Yes

Not Sure

9. Have you had pneumonia in the past 2 months?

Yes

Not Sure

10. Have you been diagnosed with, or suspected of having, obstructive sleep apnea?

Yes

Not Sure

Has anyone observed you choke, gasp, or stop breathing during sleep?

Yes

Not Sure

If YES: Check what applies to you:

I use my CPAP machine regularly

I do not regularly use a CPAP machine

11. Do you have any other breathing issues?

Yes

Not Sure

BLOOD

Yes / No / Not Sure

Comments

1. Do you take Aspirin (ASA) regularly (specify in comments)?

Yes

Not Sure

2. Do you use blood thinners other than Aspirin (ASA)? (e.g., warfarin [Coumadin], clopidogrel [Plavix], dabigatran [Pradaxa], rivaroxaban [Xarelto], Apixaban [Eliquis])?

Yes

Not Sure

3. Have you ever been treated for anemia or low red blood cell counts?

Yes

Not Sure

4. Do you or a family member have a bleeding problem (not related to blood thinners)?

Yes

Not Sure

5. Do you have any personal or religious reasons for refusing blood products?

Yes

Not Sure

6. Have you ever had a blood clot in your legs (deep venous thrombosis/DVT) or lungs (pulmonary embolism/PE)?

Yes

Not Sure

7. Do you have any viral blood diseases? (e.g. HIV, Hep B or C)?

Yes

Not Sure

KIDNEY

Yes / No / Not Sure

Comments

1. Do you have (or need) an AV fistula, dialysis, or kidney transplant?

Yes

Not Sure

2. Do you have kidney disease (other than a history of stones) or problems with the function of your kidneys?

Yes

Not Sure

ENDOCRINE

Yes / No / Not Sure

Comments

1. Do you have diabetes?

Yes

Not Sure

If YES: Check what applies to you:

2. Do you have pituitary or adrenal disease?

Yes

Not Sure

3. Do you have thyroid disease?

Yes

Not Sure

If YES: Check what applies to you:

Not well controlled (having symptoms)

OTHER

Yes / No / Not Sure

Comments

1. Are you being treated for a mental health condition (e.g. anxiety or depression)?

Yes

Not Sure

2. Have you ever had an organ transplant (other than cornea)?

Yes

Not Sure

3. Are you pregnant?

Yes

Not Sure

4. Do you take opioids (e.g. hydromorphone [Dilaudid], morphine [Statex], fentanyl, codeine, oxycodone) for chronic pain?

Yes

Not Sure

Cannabis (smoking, vaporizing, oils, or edibles)?

Yes

Other street drugs?

Yes

6. Do you drink more than 3 alcoholic drinks per day (male) or 2 alcoholic drinks per day (female)?

Yes

Not Sure

7. Have you ever had radiation treatment to the head or neck?

Yes

Not Sure

8. Do you have osteoarthritis (the most common form of arthritis)?

Yes

Not Sure

9. Do you have an autoimmune inflammatory arthritis such as rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis (these are much less common, and you would be managed by a rheumatologist)?

Yes

Not Sure

10. Do you have other autoimmune diseases (e.g. lupus or scleroderma)?

Yes

Not Sure

11. Have you needed steroids (e.g. hydrocortisone, prednisone) in the last year?

Yes

Not Sure

SPECIAL TEST HISTORY FOR HEART AND LUNGS

List any special tests you have had for your heart and lungs (stress test, heart ultrasound [echocardiogram], dye test [angiogram], sleep study, or pulmonary function tests [PFTs]):

Test

Date (approximately) (YYYY/MON)

Hospital

DISCHARGE PLANNING AND MOBILITY

Yes / No / Not Sure

Comments

1. Do you use a wheelchair, walker, cane, scooter or other aid?

Yes

Not Sure

2. Do you have a problem with your balance?

Yes

Not Sure

3. Have you had a fall in the last three months?

Yes

Not Sure

4. Do you have a responsible adult to drive you home following your surgery?

Yes

Not Sure

5. Do you have someone available to stay with you overnight and help care for you?

Yes

Not Sure

DO YOU HAVE ANY OTHER ILLNESS, LIMITATIONS OR ANY OTHER CONCERNS WE SHOULD KNOW ABOUT?

Yes

Not Sure

Citadel - Bridgewater Health History

PRIMARY DENTAL INSURANCE (if applicable)

SECONDARY DENTAL INSURANCE (if applicable)

OPERATION HISTORY

ANESTHETIC HISTORY

Yes / No / Not Sure

Comments

DO YOU TAKE ANY MEDICATIONS?

DO YOU HAVE ANY ALLERGIES?

HEART AND BLOOD VESSELS

Yes / No / Not Sure

Comments

BREATHING

Yes / No / Not Sure

Comments

GASTROINTESTINAL

Yes / No / Not Sure

Comments

BLOOD

Yes / No / Not Sure

Comments

KIDNEY

Yes / No / Not Sure

Comments

ENDOCRINE

Yes / No / Not Sure

Comments

NEURO

Yes / No / Not Sure

Comments

OTHER

Yes / No / Not Sure

Comments

SPECIAL TEST HISTORY FOR HEART AND LUNGS

DISCHARGE PLANNING AND MOBILITY

Yes / No / Not Sure

Comments

DO YOU HAVE ANY OTHER ILLNESS, LIMITATIONS OR ANY OTHER CONCERNS WE SHOULD KNOW ABOUT?

PATIENT HEALTH HISTORY QUESTIONNAIRE COMPLETED BY: