Check-In Questionnaire

Check-In Questionnaire
Patient's Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
Name of the person escorting the patient today

First NameLast Name
Escort's relationship with the patient (select all that apply)

Other
Please be sure that you and your escort have read and understood the post-anesthesia instructions:

https://www.hananesthesiology.com/_files/ugd/ef5de8_fad7eb530cf64e32866441c6df4fe342.pdf
We can email you a copy of your post-anesthesia instructions if you indicate your email address below:
example@example.com
Please note that food or drink in the stomach during anesthesia can be detrimental to the patient's safety and even to his or her life.

Note to parent/guardian of minior patient:

Your honesty and cooperation is critical for your child's safety. Please let us know if:

1) Your child (patient) inadvertently or accidentally ate or drank anything.

2. If your child (patient) was not directly monitored by parent/guardian (such as attending daycare, school, etc.).
Did the patient eat or drink anything within the last 12 hours
[IMPORTANT AND CRITICAL] Please explain what the patient ate or drank, and specify the times
Please check any symptoms the patient has had in the past 2 weeks

Other
Has any family members of the patient experienced any complications to anesthesia?
Please describe who in the family experienced complications, and what the complications were.
Is there any possibility that the patient may be pregnant?
Who is completing this form?

Other
Signature

Clear
I attest that the above statements are true to the best of my knowledge, and that any false information, omissions, or misrepresentation may impose fatal risks to the patient during anesthesia.
Should be Empty: