Central DuPage Hospital - Patients - Preparing for Surgery - Pre-Procedure Interview Questions
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Preparing For Surgery: Pre-Procedure Interview Questions
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Pre-Procedure Interview Questions

Reviewing Your Health History

This page is intended to provided patients with an understanding of the questions they can expect during the pre-procedure interview process.

The following questions will help our surgical team best meet your individual needs during your surgery. Please take a few minutes to answer these questions truthfully. Most of the questions require a simple "yes" or "no" response. If you aren’t sure, please respond "don’t know."

Questions will be posed on the following topics:


  • Have you had an acute respiratory illness this past year (pneumonia, bronchitis)?
  • Do you have asthma or wheezing?
  • Have you had tuberculosis or a positive skin test for tuberculosis?
  • Have you been in contact with anyone with tuberculosis?
  • Do you have emphysema, shortness of breath?
  • Do you use oxygen?
  • Have you been diagnosed with or shown symptoms of sleep apnea?
  • Do you use a C-Pap machine? If so, what is the setting?
  • Have you or a family member had an unusual reaction to anesthesia?


  • Do you have heart valve disease mitral valve prolapse?
  • Do you have high blood pressure?
  • Do you have chest pain or have you ever had chest pain?
  • Have you had a heart attack(s)?
  • Have you had a cardiac angiogram, angioplasty or coronary artery bypass graft?
  • Have you had a stroke? If yes, residual effects? 
  • Do you have an irregular or fast heartbeat?
  • Have you had congestive heart failure?
  • Have you had a stress test or echocardiogram within the past two years?
  • Do you see a cardiologist?
    • What is your cardiologist's name?
    • What is your cardiologist's phone number?
    • Please note:  If you see a cardiologist, we recommend that you notify him or her about your scheduled procedure.
    • Have you had a previous EKG?  If so, what was the date, location and reason?
    • Are you able to walk one block or climb two flights or stairs without chest pain or shortness or breath?

    Metabolic / Endocrine

    • Are you diabetic? If so, how is it controlled: Diet? Oral medications? Insulin?
    • Do you have thyroid trouble?
    • Have you been diagnosed with cancer in the past year? If so, what site location?
    • Have you had radiation therapy in the last year?
    • Have you had chemotherapy in the last six months?

    Hepatic / Renal / Hematology

    • Have you had any liver trouble, jaundice or hepatitis? If so, please specify.
    • Do you have renal disease or insufficiency?
    • Do you require hemo or peritoneal dialysis?
    • Do you have anemia?
    • Do you have sickle cell disease?
    • Do you have any prolonged bleeding or bruise easily?
    • Have you had a blood transfusion within the past three months?
    • Have you used aspirin or NSAIDs (non-steroidal anti-inflammatory drugs, such as Motrin, Ibuprophin, Naproxyn) in the past two weeks?
      Recommendation: Stop using aspirin or NSAIDs prior to your procedure or contact your surgeon for instructions.
    • Are you taking herbal or dietary supplements?
      Recommendation: Stop taking herbal or dietary supplements prior to your procedure or contact your surgeon for instructions.


    • Have you had polio, paralysis or meningitis?
    • Have you had any seizures?
    • Have you had a head injury with loss of consciousness within the last six months?
    • Have you had a stroke?
    • Do you have any psychological problems?

    Cultural / Social

    • Do you have any history of drug or alcohol dependency?
    • Do you drink alcohol?
      • How often do you drink alcohol?
      • How much alcohol do you drink?
      • Do you use any street drugs?
        • Which drugs have you used?
        • When were they used last?

        Pain Management

        • Are you being treated by a physician for chronic pain? If so, what is the source of your pain?


        • Have you had any back pain, injury or nerve damage?
        • Do you have arthritis?
        • Do you have any difficulty with neck extension?
        • Do you have any difficulty opening your mouth wide or having your jaw lock?
        • Do you use any assistive devices: cane, crutches, walker, wheel chair, brace, prosthesis?


        • Do you have any ulcers, reflux or heartburn?

        Nutritional Assessment

        • What is your stated height and weight?


        • Have you been pregnant in the past three months?
        • Are you possibly pregnant?

        Pediatrics – for Patients Age 12 and younger

        • Was the child born premature or full-term? How many weeks gestation?
        • Has the child ever used an apnea monitor?
        • Are immunizations up to date?
        • Has the child had rheumatic fever?
        • Has the child had a recent exposure to a contagious disease?
        • Has the child had a recent fever and/or upper respiratory infection in the past two weeks?
        • Does the child have any mental or physical disabilities?


        • Are you deaf, hard-of-hearing or use a hearing aid?
          • If you use a hearing aid: right ear, left ear or both?
          • Do you use glasses or contacts?
          • Do you have impaired vision? If so, right or left eye?
          • Do you have any objections to messages left or given regarding this procedure?
          • Should we exclude anyone from your care decisions or access to your information?

          Physician and Related Information

          • Who is your primary physician (first and last name)?
          • What is your primary physician’s phone number?
          • Are you supposed to see your primary care physician for pre-operative evaluation?
            • Name of physician you will see for pre-op evaluation if other than your PCP physician.
            • When is the date of your appointment for evaluation?
            • Do you authorize your nurse to obtain medial records from an outside source pertaining to your procedure?

            Discharge Planning

            • Who will drive you home from the hospital?
            • Who will stay with you overnight (after an outpatient procedure)?
            • Who will assist you after discharge from the hospital?

            Advance Directives

            • Do you have an advance directive, living will or healthcare power of attorney?
            • Are you willing to bring a copy to Central DuPage Hospital for your admission?

            Latex / Infection Alerts

            • Do you have any latex allergy or sensitivity?
            • Have you had an antibiotic resistant infection?


            • What medications are you currently taking?
              • At what dosage? How frequently?
              • Do you have any allergies, intolerances or side effects (such as drugs, food, environment, latex, rubber)?
              • Have you had any previous surgeries or hospitalizations?
                • If yes, when (date), what type of surgery or procedure, at which hospital (hospital name and city/state)?
                • Do you smoke? Have you ever smoked? When did you quit?
                  • How many packs do you/did you smoke per day?
                  • How many years were you a smoker?
                  • Would you like smoking cessation information?