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)*

SpouseBiologic parentAdopted parentFoster parentRelativeLegal guardianOther
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*

YesI don't know (the patient is a child, and was not monitored properly)No
[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*

NoneCoughingCongestionsRunny noseFeverMalaiseChillsLoss of tasteSore throatHad the coldHad the fluHad COVIDOther
Has any family members of the patient experienced any complications to anesthesia?*

YesNo
Please describe who in the family experienced complications, and what the complications were.*
Is there any possibility that the patient may be pregnant?*

YesNoNot Applicable
Who is completing this form?*

The patient (self)The escort indicated aboveOther
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: