Pre-Anesthesia Health Questionnaire

1. How would you describe your physical activity?

• ☐ I can run, exercise, or do heavy work without any problems
• ☐ I get tired during hard activities, but I can walk fast on flat ground or can walk uphill for about 10 minutes without stopping in between
• ☐ I can walk on flat or climb stairs or walk uphill, but I need to stop frequently due to shortness of breath, chest pain or fatigue
• ☐ I feel short of breath doing simple activities like getting dressed, bathing or walking a short distance, or even when resting
• ☐ I cannot do walking, climbing stairs or uphill walking due to knee/hip pain or back pain or other body weight

2. Do you use oxygen at home (nebulizers not applicable), have a tracheostomy, or are fully dependent on personal care?

• ☐ No
• ☐ Yes – Use oxygen, have a tracheostomy, or am fully dependent

3. Do you have a history of high blood pressure?

• ☐ No – Stop and proceed to next question
• ☐ Yes
• ☐ Often very high
• ☐ Sometimes elevated
• ☐ Currently controlled

4. Do you smoke?

• ☐ No – Stop and proceed to next question
• ☐ Yes (Cigarettes, Shisha, Medwakh)

5. Do you have any heart problems?

a. Heart attack, stent, or bypass surgery?

• ☐ No
• ☐ Yes – Within the last 6 months
• ☐ Yes – More than 6 months ago and still under treatment

b. Congestive heart failure or valve disease?

• ☐ No
• ☐ Yes – Heart failure with symptoms (fatigue, shortness of breath or limited activity)
• ☐ Yes – Severe valve disease (e.g., aortic stenosis, mitral stenosis, prosthetic valve)
• ☐ Yes – Stable heart failure
• ☐ Yes – Valve disease with symptoms (fatigue or shortness of breath)
• ☐ Yes – Valve disease without symptoms

c. Irregular heartbeat/arrhythmia or pacemaker?

• ☐ No
• ☐ Yes – Atrial fibrillation with heart rate more than 110 beats per minute
• ☐ Yes – Symptomatic irregular heartbeat/arrhythmia
• ☐ Yes – Pacemaker or implantable cardioverter-defibrillator (ICD) in place
• ☐ Yes – Controlled arrhythmia without symptoms

d. Congenital (birth-related) heart disease?

• ☐ No – Stop and proceed to next question
• ☐ Yes – Repaired or unrepaired but currently symptomatic
• ☐ Yes – Unrepaired, currently no symptoms but had symptoms in the past
• ☐ Yes – Repaired or unrepaired but no symptoms

6. Do you have breathing problems (asthma, Chronic obstructive pulmonary disease (COPD), or sleep apnea)?

• ☐ No
• ☐ Yes – Severe COPD/asthma needing oxygen or recent hospitalization in the last 3 months
• ☐ Yes – Moderate symptoms, regular inhaler use
• ☐ Yes – Mild symptoms, occasional inhaler use
• ☐ Yes – Sleep apnea not using continuous positive airway pressure machine (CPAP)
• ☐ Yes – Sleep apnea using CPAP machine
• ☐ Yes – Mild sleep apnea, no CPAP machine needed

7. Have you had a stroke, Transient Ischemic Attack (TIA), or other brain/nerve condition (Dementia, Parkinson’s, Multiple Sclerosis, Cerebral Palsy)?

• ☐ No
• ☐ Yes – Severe disability affecting speech, movement, or memory
• ☐ Yes – Stroke or TIA within last 6 months
• ☐ Yes – Stroke 6–12 months ago
• ☐ Yes – Stroke more than 1 year ago

8. Do you have epilepsy?

• ☐ No
• ☐ Yes – Vagal nerve stimulator in place
• ☐ Yes – Seizure within last year
• ☐ Yes – Well-controlled, no seizure in past year and fully recovered from previous episode

9. History of difficult airway, cardiac arrest, anaphylaxis during anesthesia, or genetic disorders (e.g., muscle disorders, malignant hyperthermia)?

• ☐ No
• ☐ Yes – e.g., malignant hyperthermia, difficult airway, anesthesia complication

10. Do you have kidney problems or are on dialysis?

• ☐ No
• ☐ Yes – Told kidneys are not working well, may need dialysis or transplant but currently not on dialysis
• ☐ Yes – Currently on dialysis
• ☐ Yes – History of kidney problems without symptoms, no dialysis needed

11. Do you have liver disease or cirrhosis?

• ☐ No
• ☐ Yes – With symptoms like ascites, confusion, or bleeding
• ☐ Yes – Diagnosed cirrhosis but stable
• ☐ Yes – Mild liver condition, no symptoms

12. Do you have diabetes?

• ☐ No
• ☐ Yes – Type 1 Diabetes on insulin pump
• ☐ Yes – On insulin or poorly controlled
• ☐ Yes – Well controlled on tablets/diet

13. Do you have any blood disorders or anemia?

• ☐ No
• ☐ Yes – Severe disorder (e.g., hemophilia, sickle cell with past crisis, major thalassemia with past multiple blood transfusions or any hereditary bleeding disorder)
• ☐ Yes – Anemia with symptoms (e.g., fatigue, shortness of breath)
• ☐ Yes – Mild anemia without symptoms

14. Do you have cancer or history of cancer?

• ☐ No
• ☐ Yes – Currently on active treatment (Chemotherapy or radiotherapy)
• ☐ Yes – In remission, no treatment in past 6 months

15. Do you take blood-thinning medications (other than aspirin)?

• ☐ No
• ☐ Yes – such as Warfarin, Apixaban, Rivaroxaban, Clexane, Clopidogrel

16. Do you have a hormone or endocrine disorder (e.g., thyroid, adrenal, pituitary)?

• ☐ No
• ☐ Yes – Pheochromocytoma
• ☐ Yes – Poorly controlled
• ☐ Yes – Well controlled