Palisades Eye Surgery Center
4831 Cordell Ave | Bethesda, MD 20814 | Phone: (301) 657-8200 | Fax: (301) 657-4121
**PLEASE COMPLETE AND BRING WITH YOU ON THE DAY OF SURGERY**
Pre-Operative Questionnaire
Patient’s Name
Gender: M / F
Date of Surgery
Ethnicity:
Operative Eye:
Height
Weight
1. Do you have a current or chronic illness?
If Yes, explain:
 Yes  No
2. Have you ever had a bad reaction to anesthesia?
If Yes, what and when:
 Yes  No
 Yes  No
4 3. Is there any possibility you could be pregnant?
 Yes  No
4. Have you been diagnosed with BPH (Benign Prostatic Hyperplasia)? Are you currently on
Flomax/Tamsulosin or Doxazosin, Uroxatral, Rapaflo?
5. Are you allergic to: Latex Yes
If Yes, describe reaction:
Betadine Yes
Codeine Yes
Eggs Yes
Sulfa Yes
6. Are you allergic or sensitive to any foods, medications or other?  Yes  No
If Yes, what and describe reaction:
7. What medications are you taking? List name, amount, how often, and the reason for taking medication.
Drug/Amount
8. Have you ever had:
Heart Disease
Rheumatic Fever
Heart Attack
Chest Pain
Stroke
HIV/AIDS
Sleep Apnea
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
How Often
 No
 No
 No
 No
 No
 No
 No
High Blood Pressure
Tuberculosis
Kidney Disease
Bleeding Problems
Seizures
Hepatitis
Glaucoma
Reason
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 No
 No
 No
Asthma
Diabetes
Jaundice
Ulcers
Back Trouble
Cancer
Mental Illness
If Yes, did you receive any treatment? Describe:
9. Are you currently taking any anticoagulants (Aspirin, Coumadin, Plavix, etc.)?  Yes  No
10. Do you tend to bleed easily?  Yes  No
11. Do you smoke?  Yes  No
12. Do you use alcohol?  Yes  No
If Yes, for how long?
If Yes, how much?
How much?
How often?
13. Do you have any dentures?  Yes  No
14. Do you have any medical condition that you feel your Anesthesiologist should know about?
Questionnaire completed by
Document1
Relationship to patient
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 No
 No
 No