Arthur M. Blank Hospital Pre-anesthesia Form | Children's Healthcare of Atlanta

Arthur M. Blank Hospital Surgical Services

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

Child's First Name

Child's Last Name

Nickname

Surgeon

Other Surgeon's Name?

Pediatrician Name

Pediatrician Phone

Today's Date

Date Of Birth

Age

Sex

*Height (feet) (inches)

*Weight (pounds)

Body Mass Index(BMI) - If you're unsure of your child's height or weight please estimate. All patients will be weighed on the day of procedure.

Date Of Surgery

Operation

List previous dates of hospitalization(s) and surgeries for your child. Include reasons for hospitalization(s) and type of surgery.

Date (mm/dd/yyyy)	Reason/Type of surgery
Date (mm/dd/yyyy)	Reason/Type of surgery
Date (mm/dd/yyyy)	Reason/Type of surgery
Date (mm/dd/yyyy)	Reason/Type of surgery
Date (mm/dd/yyyy)	Reason/Type of surgery

Has your child had any surgeries cancelled in the last 3 months? Yes No

If yes, why? *Please explain.

Has your child had any tests, xrays or bloodwork in the last three months or ever had a sleep study? Yes No

If yes, please explain: *Please explain.

Has the child ever had general anesthesia? Yes No

Reason: *Required

Did your child have any serious problems with anesthesia?: *Please explain

Do you have any family members or family history of issues with anesthesia, such as, malignant hyperthermia or pseudocholinesterase deficiency? Yes No

If yes, explain. *Please explain.

Does the child have any medication, food or latex allergies? Yes No

Allergies *Allergies	Type of Reaction *Type of Reaction
Allergies	Type of Reaction
Allergies	Type of Reaction
Allergies	Type of Reaction
Allergies	Type of Reaction

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.

Does the child currently take any medication? Yes No

Medication *Medication	Why is your child taking it? *Why is your child taking it?
Medication	Why is your child taking it?
Medication	Why is your child taking it?
Medication	Why is your child taking it?
Medication	Why is your child taking it?

Does your child take Vitamins/Herbs? Yes No

Vitamins/Herbs *Vitamins/Herbs	Why is your child taking it? *Why is your child taking it?
Vitamins/Herbs	Why is your child taking it?
Vitamins/Herbs	Why is your child taking it?
Vitamins/Herbs	Why is your child taking it?
Vitamins/Herbs	Why is your child taking it?

Does your child take Antibiotics? Yes No

Antibiotics *Antbiotics	Why is your child taking it? *Why is your child taking it?
Antibiotics	Why is your child taking it?
Antibiotics	Why is your child taking it?
Antibiotics	Why is your child taking it?
Antibiotics	Why is your child taking it?

Does your child currently take Thickening agents and/or medication thickeners? Yes No

Thickening Agents *Thickening Agents	Why is your child taking it? *Why is your child taking it?
Thickening Agents	Why is your child taking it?
Thickening Agents	Why is your child taking it?
Thickening Agents	Why is your child taking it?
Thickening Agents	Why is your child taking it?

How does your child prefer to take medication?

Has your child taken aspirin, ibuprofen, Advil, Motrin or Tylenol/acetaminophen in the last 7 days? Yes No

Last date taken : *Please enter date

What medications does he/she take occasionally?

Does your child have sickle cell disease?

Does your child have the sickle cell trait?

Your name:

Relationship to child:

Other: *What is your relationship to the child?

DFAC Phone: *DFAC Phone is required.

Mobile Phone number:

Secondary Phone number:

Work Phone number:

Preferred time to call: Anytime Daytime Evening

Email Address

Do you give us permission to access medical records from your child's specialist? Yes No

Any comments you have to share with us concerning your child?

Transportation to surgery and home:

Other Transportation *Please specify what kind of transportation will be used.

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

Is your child 18 years of age or older? Yes No

Does your child have an existing Advance Directive? Yes No *Please select

(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.

* Required fields

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Children’s License Agreement

Surgery

Arthur M. Blank Hospital Surgical Services

Pre-anesthesia History Form