Ambulatory Surgery Center Questionnaire

Pre-Admission Questionnaire

Hutchinson Ambulatory Surgery Center
* = required field
Patient's Name:*

First NameMiddle NameLast NameSuffix
Patient's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Cell Phone #:*

Area CodePhone Number
Patient's Home Phone #:*

Area CodePhone Number
Patient's Work Phone #:*

Area CodePhone Number
Surgery Date:*

MonthDayYear
Proposed Surgery:*
Doctor Performing Surgery:*

INSURANCE INFORMATION
Person Insurance Is Through:*
Insured Date of Birth:*

MonthDayYear
Insured Social Security Number:*
Insured Employer:*
Name of Insurance Company:*
Address of Insurance Company:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone # of Insurance Company:*

Area CodePhone Number
Identification # of Insurance:*
Group # of Insurance:*
Medical History:*
Surgery History:*
Medication History:*
Drug Allergies:*

ANESTHESIA INFORMATION
Complete if patient is going to surgery.
Patient Name:*

First NameLast NameSuffix
PASS VisitTelephone InterviewInpatient
Date of Surgery:*

MonthDayYear
Date Questions Completed:*

MonthDayYear
TO BE COMPLETED BY THE PATIENT OR FAMILY/SIGNIFICANT OTHER
1. Do you smoke?:*

YesNo
If yes, how many packs a day? How many years?:
2. Do you use any illegal drugs?:*

YesNo
3. Do you have a cough?:*

YesNo
If yes, do you bring anything up when you cough?:
4. Do you currently have or ever had asthma?:*

YesNo
5. Do you have a cold?:*

YesNo
6. Have you ever had an abnormal chest x-ray?:*

YesNo
7. Have you ever had any difficulties breathing?:*

YesNo
8. Do you become short of breath walking up 2 flights of stairs?:*

YesNo
9. Have you ever had pulmonary function testing?:*

YesNo
10. Are you ever short of breath when lying down at night?:*

YesNo
11. Do you have a heart murmur?:*

YesNo
12. Have you ever had angina or pain in the chest related to your heart?:*

YesNo
13. Have you ever had a heart attack?:*

YesNo
If yes, when?:

MonthDayYear
14. Do you have a Mitral Valve Prolapse?:*

YesNo
15. Have you ever had an abnormal EKG?:*

YesNo
16. Have you ever had other cardiac testing?*

EchocardiogramMUGATreadmill/Stress TestHeart CatheterizationOther
17. Have you ever had high blood pressure?:*

YesNo
18. Have you ever had other heart problems not listed?:*

YesNo
19. Have you ever had hepatitis?:*

YesNo
20. Do you have a hiatal hernia or get heartburn?:*

YesNo
21. Do you use alcohol?:*

YesNo
22. Have you ever had a stroke?:*

YesNo
If yes, when?:

MonthDayYear
23. Do you have an arm or leg that becomes numb or weak?:*

YesNo
24. Have you ever had seizures, episodes of unconsciousness or fainting?:*

YesNo
25. Do you have frequent headaches?:*

YesNo
26. Have you ever been diagnosed with sleep apnea or do you utilize a CPAP machine?:*

YesNo
27. Do you have diabetes?:*

YesNo
28. Do you take insulin?:*

YesNo
29. Have you ever had thyroid problems?:*

YesNo
30. Do you have back or neck problems?:*

YesNo
31. Do you have arthritis?:*

YesNo
If yes, where?:
32. Do you have any physical disabilities?:*

YesNo
If yes, please list:
33. Have you ever had kidney disease?:*

YesNo
34. Have you ever been jaundiced?:*

YesNo
35. Have you taken cortisone/prednisone in the past year?:*

YesNo
36. Do you have any bleeding tendencies?:*

YesNo
37. Have you ever had a blood transfusion?:*

YesNo
38. Have you given your own blood for this surgery?:*

YesNo
If yes, how many units?:
39. Have you ever been anemic?:*

YesNo
40. Have you used aspirin in the past 2 weeks?:*

YesNo
If yes, how much?:
41. Have you ever had cancer?:*

YesNo
42. Have you ever taken chemotherapy?:*

YesNo
If yes, what?:
43. Do you have any chipped or loose teeth?:*

YesNo
44. Do you have?:*

DenturesCapsBridgeworkBracesOther
45. Have you ever had an anesthetic?:*
46. Have you ever had a problem with anesthesia? If yes, what?:*
47. Has anyone related to you ever had a problem with anesthesia? If yes, what?:*
48. Is there anything else you feel you should tell us regarding your health?:*
Should be Empty:

Pre-Admission Questionnaire