Arthur M. Blank Hospital Pre-anesthesia Form | Children's Healthcare of Atlanta

Child's First Name

Child's Last Name

Nickname

Surgeon

Other Surgeon's Name?

Pediatrician Name

Pediatrician Phone

Today's Date

Date Of Birth

Age

Sex

Height (feet) (inches)

Weight (pounds)

Body Mass Index(BMI) - If you're unsure of your child's height or weight please estimate. All patients will be weighed on the day of procedure.

Date Of Surgery

Operation

The child's general health is:

Does your child have any chronic health issues? Yes No

If yes, please explain: *Please explain.

Immunizations up to date? Yes No

Specify if no: *Please explain.

Has your child tested positive for COVID? Yes No

If yes, when? (please specify date): *Please specify date.

Has you child received two Covid Vaccines? Yes No

Please bring your Covid Immunization Card the day of surgery.

Has your child been exposed to any of the following common diseases within the past 21 days?

Chickenpox or shingles? Yes No

If yes, when? (please specify date): *Please specify date.

Measles? Yes No

If yes, when? (please specify date): *Please specify date.

German Measles? Yes No

If yes, when? (please specify date): *Please specify date.

Other Infections? Yes No

If yes, please explain? When?(please specify date also): *Please explain.

In the last 24 hours has your child had:

Fever (temperature > 100 F)? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Cough? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Shortness of breath? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Sore throat? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Diarrhea? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Vomiting? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Congestion? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Muscle Aches? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

If they develop any of these prior to surgery, please call your physician to discuss rescheduling.

Is he/she sick today? Yes No

If yes, please explain: *Please explain.

Any illness in the past three months, such as pneumonia, bronchitis, bronchiolitis, that required an inhaler or breathing treatment? Yes No

If yes, when? (please specify date): *Please specify date.

Is your child using an inhaler or breathing treatment now? Yes No

If yes, please explain: *Please explain.

List previous dates of hospitalization(s) and surgeries for your child. Include reasons for hospitalization(s) and type of surgery.

Date (mm/dd/yyyy)	Reason/Type of surgery

Has your child had any surgeries cancelled in the last 3 months? Yes No

If yes, why? *Please explain.

Has your child had any tests, xrays or bloodwork in the last three months or ever had a sleep study? Yes No

If yes, please explain: *Please explain.

Has the child ever had general anesthesia? Yes No

Reason:

Did your child have any serious problems with anesthesia?: *Please explain

Do you have any family members or family history of issues with anesthesia, such as, malignant hyperthermia or pseudocholinesterase deficiency? Yes No

If yes, explain. *Please explain.

Does the child have any medication, food or latex allergies? Yes No

If yes, to what? Type of reaction? *Please explain.

Important Information Needed on the Day of Your Child's Surgery: Please bring a list of the names and exact dosage of all medicine (including vitamins and herbal medicine) your child is currently taking with you on the day of surgery. This is very important so that we can prescribe the right medicine for your child after surgery.

Does the child currently take any medication? Yes No

Medication	Why is your child taking it?

How does your child prefer to take medication?

Has your child taken aspirin or ibuprofen in the last 7 days? Yes No

Last date : *Please enter date

What medications does he/she take occasionally?

Does your child have sickle cell disease?

Does your child have the sickle cell trait?

Does your child have any or has your child had any of the following?

Current or history of heart, blood, bleeding or clotting issues? Yes No

Heart Defect

Bleeding Problems

Heart Murmur

If yes, were you told it is an innocent murmur? Yes No

Any Blood Transfusions

Other

List

Do you see any Specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(B) Lung or breathing issues Yes No

Asthma/Wheezing

When?

Croup

When?

Chronic Bronchitis

When?

Cystic Fibrosis

Pneumonia

When?

Other

List Other

Do you see any specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(C) Neurological system issues Yes No

(D) Digestive system issues Yes No

Hepatitis

Intestines or Bowels

Liver

Gastro-Esophageal Reflux

Stomach

Overweight

Other

List

Do you see any specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(E) Endocrine system issues Yes No

Diabetes

Thyroid

Other

List

Do you see any specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(F) Issues at birth or was born prematurely Yes No

(G) Kidney or bladder issues Yes No

Explain:

Please explain.

Do you see any specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(H) Menstruation has started Yes No

Date of last menstrual period: (mm/dd/yyyy) *Date of last menstral period required (mm/dd/yyyy).

Is there any possibility of pregnancy? Yes No *Please select

If your child is 12 or older, or has started her menstrual cycle, we will need a urine specimen upon arrival to the surgery center.

(I) Muscle, bone or joint issues Yes No

Muscle Disorder

Bone Disease

Joint Disease

Rheumatoid Arthritis

Other

List:

Do you see any specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(J) Teeth issues Yes No

Bleeding gums and cavities?

Any loose?

Any missing?

Any chipped or capped?

Dental Appliance

Type:

Do you see any specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(K) Cancer / Chemotherapy Yes No

Type: *Chemotherapy type is required.

Do you see any specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(L) Hearing aid / Glasses / Prosthesis Yes No

Hearing Aids

Glasses

Contacts

Prosthesis

Do you see any specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(M) Other health problems / Syndromes / Chromosomal abnormalties / Genetic problems Yes No

Explain *Please explain

Do you see any specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(N) Mental health problems Yes No

Diagnosis: *Diagnosis is required.

Do you see any specialist? Yes No

Name: *Specialist name is required.

Phone: *Specialist phone number is required.

(O) Is caretaker of patient pregnant? Yes No

Have you or anyone in your household had the following symptoms in the last 24 hours?

Fever (temperature > 100 F)? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Cough? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Shortness of breath? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Sore throat? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Diarrhea? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Vomiting? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Congestion? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

Muscle Aches? Yes No

If yes, is this related to any known medical or chronic condition?: *Please explain.

If you develop any of these symptoms, you may not accompany your child on the day of their procedure and may want to contact your child’s physician to consider rescheduling.

Your name:

Relationship to child:

Other: *What is your relationship to the child?

DFAC Phone: *DFAC Phone is required.

Mobile Phone number:

Secondary Phone number:

Work Phone number:

Preferred time to call: Anytime Daytime Evening

Email Address

Do you give us permission to access medical records from your child's specialist? Yes No

Any comments you have to share with us concerning your child?

Transportation to surgery and home:

Other Transportation *Please specify what kind of transportation will be used.

You need to have arranged for transportation home prior to the day of surgery.

Is your child 18 years of age or older? Yes No

Does your child have an existing Advance Directive? Yes No *Please select

(An Advance Directive is a legal way to make a decision about future medical care. A life threatening illness or injury can happen to anyone at any age. You can help control your care by recording your choices. The time to do this is before you are sick or injured). If your child already has an Advance Directive, please bring it with you on day of surgery. If you want more information, visit our Website and click on the link for Advance Directives. If you would like to speak with someone about Advance Directives, please call our Communication Nurse at 404-785-6712.

One day before surgery, you will be contacted with arrival time and specific eating and drinking instructions for the day of your child's procedure.

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