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Microsoft word - preopquestionnaire.doc

JANE E. GRAEBNER, D.P.M.
PRE-OPERATIVE QUESTIONNAIRE
Date Form Completed:
Current Address:
Zip Code:
Phone: Home (
Answering Machine: Y N Best Time to Call:
Extension #:
Best Time to Call:
E-mail Address:
Legal guardian/parent (if under 18 years old):
List ALL medications you are currently taking (include dosage & REASON PRESCRIBED):
1)

Circle One
Are you taking a blood thinner such as Aspirin, Coumadin, Warfarin, Pletal?
Are you currently taking Plaquenil or Methotrexate?
Can you take the following medications:
Penicillin?
Sulfa Antibiotics?
Aspirin?
Codeine?
List all Allergies:
Do you have any allergies to metals (such as Nickel)?
Do you have any allergies to suture materials (such as Nylon)?
Are you allergic or sensitive to:
Adhesive Tape/Band-Aids?
Iodine/Betadine?
Local Anesthetics (i.e. Novacaine, Xylocaine)?
Have you ever had a reaction of any kind from a local anesthetic injection?
Has it ever taken more local anesthetic to produce numbness for you?
Have you or any member of your family ever had difficulty with anesthesia of any
kind (i.e. spinal, general, IV sedation, local anesthesia)?

If yes please explain:

Have you ever had any problems with anesthesia (i.e. general, spinal or IV
sedation) such as nausea, vomiting, difficulty becoming alert?

If yes please explain:
Have you ever had trouble with a pain medication (i.e. sick to your stomach,
headache, constipation?

If yes please explain:
Do you have high pain tolerance (can you tolerate a lot of pain)?
Do you have a low pain tolerance (cannot tolerate much pain)?
Does a specific pain medication work well for you or member of you family?
If yes, please list:
List your last three (3) surgeries of any kind including the date, where performed,
and the surgeon:

Have you ever had heart by-pass surgery?
Have you ever had surgery to improve the circulation in your legs?
Have you ever had difficultly healing a wound?
If yes, please explain:
Have you ever had post-operative infection?
Have you ever had a scar that does not look nice (i.e. enlarged, reddened)?
Have you ever needed an antibiotic prior to dental work or surgery?
Do you have mitral valve prolapse?
Do you have a heart murmur?
Do you have an artificial valve in your heart?
Have you ever had rheumatic fever?
Do you have sleep apnea?
If yes: CPAP, or BIPAP? Machine settings
Are you prone to infections?
Have you ever had joint replacement surgery?
Have you been anemic or had low iron in your blood?
Have you ever had a blood clot in your leg(s)?
Have you ever had a blood clot in your lung (pulmonary embolus)?
Have you ever had trouble with the veins in your legs (i.e. varicose veins,
phlebitis)?

Do you have trouble with swelling in your legs?
If yes, please explain:
Have you ever been diagnosed with Fibromyalgia?
Do you have trouble sleeping at night?
Have you ever had Polio?
Have you ever had Hepatitis?
Have you ever had AIDS?
Have you ever tested as HIV positive?
Have you ever worn a cast before:
If yes, did any problems occur?
Do you smoke cigarettes/cigars/chew tobacco?
If yes, how many per day?
Do you consume much caffeine?
If yes, how much in one (1) day?
Do you drink alcohol?
If yes, how much in one (1) day? ______________ one (1) week? ____________
Do you drink milk or eat dairy products?
Do you take vitamins?
Calcium?
Have you ever used crutches?
Have you ever used a walker?
Do you own crutches?
Do you own a walker?
Do you have trouble with your knees?
Your hips?
Your back?
Do you have a difference in the length of your legs?
If yes, please explain:
Do you usually wear an orthotic, arch support, or supportive shoes?
What is you shoe size?

Source: http://www.faawc.com/docs/PreOpQuestionnaire.pdf

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