Patient Questionnaire (Adult)
Pre-Surgical Health History
Bar Code Area Form ID
Page: 1 of 4
Legal Name _______________________
Care Card No. _____________________
Birth date: Day __ Month __ Year ____
Female 
Male 
Rev: Oct 23, 2013
Legal Name
COMPLETE ALL 4 PAGES: WRITE N/A IF QUESTION
DOES NOT APPLY.
______________________
Care Card No.
____________________
Address ___________________________________________________________________________
Birth date: Day __ Month __ Year
E-mail ______________________Home Phone _______________Mobile
Phone_________________
____
 about?
Male 
Do you have cultural or religious beliefs you would like usFemale
to know
If yes, Explain:________________________________ Primary Language_______________________
Form completed by:  Patient
 Family member, Friend, Other Name______________________
HEIGHT:
WEIGHT:
Do you have any allergies to medicine, food or environment (including latex, rubber gloves)?
Yes  No 
If yes, list below.
Allergy / Sensitivity
How you react:
Have you had surgery in the past? Yes  No 
Date
What surgery did you have?
If yes, write below.
What hospital / city?
Have you or a blood relative had problems with local freezing or general anesthetic?  Yes  No
If yes, explain: ______________________________________________________________________
Screening for Sleep Apnea :
A. Have you been diagnosed with sleep apnea (stop breathing while you are asleep)?
B. Do you have a CPAP machine, or dental device to help you breathe while sleeping?
If you answered NO to “A” and “B”, complete questions 1 to 4:
1. Do you snore loudly (louder than talking or can be heard through closed doors)?
2. Do you often feel tired, fatigued, or sleepy during daytime?
3. Has anyone observed you stop breathing during your sleep?
4. Do you have or are you being treated for high blood pressure?
Yes 
Yes 
No 
No 
Yes 
Yes 
Yes 
Yes 
No 
No 
No 
No 
Have you or do you smoke tobacco / cigarettes?
Yes 
No 
If yes, Number/Day _____________Number of years___________Date last cigarette__________________
Ongoing breathing or lung problems
Yes 
No 
If yes, what type:
Page:2 of 4
Patient Questionnaire (Adult)
Pre-Surgical Health History
Bar Code Area
Form ID
Do you have or have you had any of the following:
Ongoing problems swallowing,
Yes No
chewing or opening your mouth
Nausea or vomiting after surgery
Yes No
Confusion after surgery
Yes No
Seizures. Date of last:________
Yes No
Spine injury
Yes No
Back or neck pain or deformity that
Yes No
limits movement
Parkinsons
Yes No
Multiple Sclerosis
Yes No
Muscle disease:
Type:____________
Angina, chest pain or pressure
Yes
No
Yes
No
Hiatus hernia
Yes
No
Ongoing heart burn or acid reflux
Yes
No
Stomach ulcers
Yes
No
Cirrhosis
Kidney disease. Type:___________
Dialysis: Hemo  Peritoneal
Infection: HIV TB
 Hepatitis type: _____________
Do you suffer from anxiety or panic
attacks?
Yes
Yes
Heart attack
Pacemaker or heart defibrillator
Heart beat: too fast  irregular
Heart failure
Heart valve problem
Heart murmur
Blood clot in lung or leg
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Stroke or TIA. Date:____
Recent or ongoing problems with
dizzy spells or fainting
High blood pressure
Yes
Yes
No
No
Yes
No
Blood diseases or bleeding
Yes
No
problems: Type:________
Are you able to climb two flights of stairs?Yes No If no, why?  short of breath  too tired  chest pain
List the name of any specialist
you’ve seen.
 Heart /cardiac Dr.
 Lung/respirologist Dr.
√ below to any test you’ve had.
 Exercise test or treadmill
 Holter monitor for 24 hours
 Heart cath or angiogram
Yes
No
Yes
No
Yes
No
No
No
Women: Could you be pregnant?
If yes, how many
weeks?_______
Thyroid problem:
Type:__________
Diabetes - Controlled by:
 Insulin  Pills  Diet
Osteoarthritis
Rheumatoid arthritis
Yes
Yes
No
No
Yes
No
Lupus
 Yes
No
Yes
No
Cancer:
Yes
No
Type__________________
chemo  radiation
Last dose:_________________
Date of last
List the name of any specialist
Date of last
visit
you’ve seen.
visit
 Blood/haematologist Dr.
 Neurologist Dr.
Where When √ below to any test you’ve had.
Where When
 Heart echo test or heart
ultrasound
 Heart scan MIBI
 Pulmonary lung function test
Patient Questionnaire (Adult)
Pre-Surgical Health History
Bar Code Area
Page:3 of 4
Form ID
Do you take any over the counter or prescribed medicines? Any vitamins? Any herbal? Write below
(or attach list)
Medication
Dose
How often?
Medication
Dose
How often?
Pain
For Staff Only:  Further Assessment  Care Plan Initiated
In the past 2 weeks, have you had any pain most days or has any part of
 Yes  No  Not sure
your body hurt most days?
In the past 2 weeks:
Have you taken or used any medicine for pain?
 Yes
 No  Not sure
Have you done other things or used other products to help reduce your
 Yes  No  Not sure
pain? This could include using heat or cold, massage, deep breathing,
ointments, or herbal remedies.
Medications
For Staff Only:  Further Assessment  Care Plan Initiated
In the past 2 weeks, have you taken or used any medicines, either
 Yes  No  Not sure
regularly or when needed?
This could be medicines ordered by your doctor or ones you bought
on your own from a pharmacy, health food or herbal medicine store.
Did you have health or medical problems before coming to the hospital?
 Yes  No  Not sure
This does not include the reason you came to the hospital.
In the last 7 days, have you taken any antibiotics?
 Yes
 No
 Not sure
In the past 28 days, have you or your doctor changed the medicines you
are taking?
‘Changed’ meaning the amount of medicine you take, how often you
take the medicine, or if you have stopped or started taking a
medicine.
 Yes
 No
 Not sure
Eating and drinking
For Staff Only:
Have you lost weight recently without trying?
 Further Assessment
Yes
 Care Plan Initiated
No
Not sure
If ‘Yes’ how much weight have you lost?
 Unsure  1 to 5 kilograms (2.2 to 11 pounds)  6 to 10 kilograms (13-22 pounds)
 11 to 15 kilograms (24 to 33 pounds)  More than 15 kilograms (more than 33 pounds)
Have you been eating poorly because of a decreased appetite?
Yes
No
Have you had any trouble swallowing food or drinks?
Yes
No
Have you had any trouble chewing food?
Yes
No
Have you been repeatedly treated with antibiotics for lung problems?
Yes
No
Have you needed help making meals?
Yes
No
Have you needed help to feed yourself?
Yes
No
Not sure
Not sure
Not sure
Not sure
Not sure
Not sure
Patient Questionnaire (Adult)
Pre-Surgical Health History
Bar Code Area
Page:4 of 4
Form ID
Going to the toilet
For Staff Only:  Further Assessment Care Plan
Initiated
In the past 2 weeks, have you had any problems urinating (going
 Yes  No  Not sure
pee’)?
Problems could include pain, going more often, trouble going,
feeling the need to go right away, or leaking.
In the past 2 weeks, have you had any problems with your bowel
movements (going ‘poo’)?
Problems could include being constipated or having diarrhea.
 Yes  No
 Not sure
Do you need help going to the toilet?
 Yes  No
 Not sure
Moving around – How mobile are you?
For Staff Only:  Further Assessment
Initiated
Do you usually use a walking aid such as a cane or walker?
 Yes  No
In the past 2 weeks, have you had any trouble doing any of the
following:
 Getting out of bed or out of a chair?
 Getting dressed, bathing, or showering?
 Walking?
 Climbing stairs?
If ‘Yes’ to any of these, could you only do it with someone’s help?
 Yes
 Yes
 Yes
 Yes
In the last 6 months, have you fallen, tripped, slipped, or almost
fallen?
Thinking, mood, and memory
Initiated
In the past 2 weeks:
 Not sure
 No
 No
 No
 No
 Not sure
 Not sure
 Not sure
 Not sure
 Yes  No
 Not sure
 Yes  No
 Not sure
For Staff Only:  Further Assessment
 Have you at any time felt confused or uncertain about what is
going on around you?
 Care Plan
 Care Plan
 Yes  No
 Not sure
 Have you found it harder to think, focus on things, or remember  Yes  No
to do certain things?
 Not sure
 Have you felt sad, down, or not interested in life?
 Yes  No
 Not sure
 Have you trouble getting interested or feeling pleasure in
doing things you usually enjoy?
 Yes  No
 Not sure
 Yes  No
 Not sure
If you said ‘Yes’ to any of these questions, has this made it hard for
you to do activities such as get dressed, make meals, go grocery
shopping, or visit with family or friends?
For staff: Reviewed & Initial
Admitting nurse: Reviewed & Initial
Date:
Date:
Time:
Time: