Children's Healthcare of Atlanta

Surgery

Arthur M. Blank Hospital Surgical Services

Pre-anesthesia History Form

If you have any questions, contact the presurgery phone nurse: 404-785-6712.

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

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*Required
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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.

*Please enter date
*Specialist name is required.
*Specialist phone number is required.
*Please list date, location and any reaction.
*Specialist name is required.
*Specialist phone number is required.

Bring all breathing equipment, including oxygen tank day of surgery.

*Specialist name is required.
*Specialist phone number is required.
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*Specialist name is required.
*Specialist phone number is required.
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*Please specify how many weeks premature.
*Please specify birth weight.
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If yes, please explain. Otherwise, enter No.
*Date of last menstral period required (mm/dd/yyyy).
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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.

*Specialist name is required.
*Specialist phone number is required.
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*Chemotherapy type is required.
*Specialist name is required.
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*Specialist name is required.
*Specialist phone number is required.
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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.

*What is your relationship to the child?
*DFAC Phone is required.
*Please specify what kind of transportation will be used.

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

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(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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