Policy Name:
Pre-Anesthesia Evaluation
Section:
Anesthesia
Policy #:
Purpose
To establish guidelines for particulars to be included in the pre-anesthetic
medical history and physical exam.
Approved Date
Reviewed Date
Revised Date
POLICY
PRE-ANESTHETIC HISTORY
A patient's medical history is obtained at the time of the pre-anesthetic evaluation and is to include:

Previous anesthesia experience.

Family health/anesthesia experience.

Current drug usage.

Allergies/Reactions.

Drug abuse/addiction.

Smoking/alcohol use.

Obstetric history (as appropriate).
SYSTEM REVIEW
 Cardiovascular

Pulmonary

Renal

Gastrointestinal/hepatic

Neurological

Endocrine

Hematological

Dental/oral problems
Review old medical records.
PHYSICAL EXAMINATION
Physical examination is performed that relates to the possibility of occurrence of anesthetic
complications.

Auscultation heart and lungs.

Blood pressure, pulse assessment of teeth, oropharynx; ability to open mouth, extend neck.

Assessment for ease of IV access.

Additional physical exam per anesthetic technique (regional block, spinal, epidural) and/or
surgical procedure (position).