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
- 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?
- 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?
- 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?
- 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?