Hoag Orthopedic Institute Preoperative History Questionnaires

The following online preoperative questionnaire intake forms are required.

Please begin with step 1 Patient History Questionnaire.
Please fill out each form as completely as possible. All forms are required to be completed.
The Activity Assessment, Home Medications and Sleep Apnea Screening will become available once Patient History has been completed.

NOTE: Once you start the questionnaires, you must complete all in one session!
if you navigate to another site or close the browser, you will lose what you have entered and will have to start over.

1 Patient History Questionnaire Please Start Here
2 Activity Assessment
3 Home Medication List
4 Sleep Apnea Screening
5 Review/Submit

All Fields marked with are Required

Patient Last Name:

Patient First Name:

Patient Middle Name:

Email Address:

Primary Phone #

Is Mobile Phone?

Cell Phone #

Date of Birth:

Gender:

Height:

Weight:

Contact Name:

Contact Phone #

Surgeon Name:

Surgery Date:

Prior Visit to Hoag?

If Yes, when?

Interpreter Needed?

If Yes, for what Language?

Primary Care Physician:

Physician Phone #

Physician Fax #

Cardiologist:

Cardiologist Phone #

Cardiologist Fax #

Pharmacy:

Pharmacy Address:

Pharmacy City:

Pharmacy Phone #

Date of Previous Lab Work:

Location:

ALLERGIES AND ALLERGIC REACTIONS

Do you have any allergies?

(Drugs, food, surgical tape, etc...)

Add Allergy

	Allergy	Reaction
No Allergies Added

Are you allergic to Latex?

If Yes, Reaction:

Are you allergic to Metals?

If Yes, Type/Reaction:

SURGERIES AND HOSPITALIZATIONS

Have you had problems with Anesthesia?

If Yes, please explain:

Has your family had problems with Anesthesia?

If Yes, please explain:

Will you accept blood products?

Add Surgery

	Surgery/Hospitalization	Year	Complications
No Surgeries/Hospitalizations Added

Please check if you had any of the following	Year	Where test and/or procedure was done
EKG
Stress Test
Echocardiogram
Angioplasty
Cardiac Surgery
Specify Cardiac Surgery:
Other Procedure
Specify Other Procedure:
Pacemaker/AICD
Date Last Checked:
Pacemaker/AICD Model:

Have you had any of the following vaccines:

Flu Vaccine?

What Year?

Pneumonia Vaccine?

What Year?
Pneumovax Prevnar 13

COVID-19 Vaccine?

Dose 1: Dose 2: Dose 3:

Smoking History:

Have you ever smoked?

For how many years?

Year Quit?

Do you currently smoke?

For how many years?
How many per day on average?

Have you smoked in past 12 months?

Alcohol History:

Do you drink alcohol?

How much Alcohol and how often?

Drug History:

Do you use recreational drugs?

Last used:

What kind of drugs do you use?

For Female Patients:

Any possibility of Pregnancy?

Last Menstrual period:

Social History:

Do you live alone?

With whom do you live?

Do you have stairs?

Do you have someone to assist at home?

Are you presently employed?

What type of work?

Are you retired?

Do you wear contacts?

Are you legally blind?

Do you wear hearing aids?

Are you hearing impaired?

Do you have caps, bridges, dentures or loose teeth?

Do you exercise?

Type of Exercise:

Duration/Frequency:

Additional information, comments or concerns?

Go to step 2 Activity Assessment Go back to Instructions

Please answer questions below regarding your ability to do these activities as if you did not have pain or mobility issues.
We want to know how well your heart and lungs function.

All Fields marked with are Required

1.	Can you take care of yourself (eating, dressing, bathing or using the toilet)?
2.	Can you walk indoors, such as around your house?
3.	Can you walk a block or two on level ground?
4.	Can you climb a flight of stairs or walk up a hill?
5.	Can you run a short distance?
6.	Can you do light housework around the house, such as dusting or washing dishes?
7.	Can you do moderate work around the house, such as vacuuming, sweeping floors or carrying in groceries?
8.	Can you do heavy work around the house, such as scrubbing floors or lifting and moving heavy furniture?
9.	Can you do yard work such as raking leaves, weeding, or pushing a power mower?
10.	Can you have sexual relations?
11.	Can you participate in moderate recreational activities such as golf, bowling, dancing, doubles tennis, or throwing a baseball or football?
12.	Can you participate in strenuous sports, such as swimming, singles tennis, football, basketball or skiing?

Go to step 3 Medication Reconciliation Go back to 1 Patient History

All Fields marked with are Required

Add Medication(s)

OR

Check this box if not on any home medications.

Describe Allergies/Reactions:
Completed By:
Source of Medication History:

	Medication	Dose	Route	Frequency	Reason for Taking
No Medications Added

Acknowledgement: I confirm that this is a complete and accurate list of my current medications to the best of my knowledge, including prescription and over the counter drugs.
I agree to discontinue all herbal and nutritional supplements 7 days prior to surgery. I understand that healthcare providers will make medical decisions based on this information.

Go to step 4 Sleep Apnea Screening Go back to 2 Activity Assessment

All Fields marked with are Required

Do you snore loudly (louder than talking or loud enough to be heard through closed doors?

Do you often feel tired, fatigued or sleepy during the daytime?

Has anyone observed you stop breathing during your sleep?

Are you being, or have been, treated for high blood pressure?

Is your body mass index greater than 35 (weight in lbs/height in inches)?

Calculate

Your calculated BMI: BMI Chart

Are you more than 50 years old?

Is your neck circumference greater than 17 inches (in men) or 16 (in women)?

Are you male?

Have you ever had radiation to the neck?

If you answer YES to three or more criteria above, speak to your primary care physician, surgeon or the nurse.
If you already have known sleep apnea, bring CPAP headgear and mask to hospital for your procedure.

Do you currently use a CPAP machine?

If Yes, Current Setting:

Go to step 5 Final Review Go back to 3 Medication Reconciliation

Final Review, Signature and Submission

All Fields marked with are Required

Please review the completed questionnaires for accuracy and missing information.
You may want to provide additional information or make changes to your previosuly supplied responses.

To navigate, click on the desired numbered tab or select the desired questionnaire from the "Back To Questionnaire" selection below.

Once you are satisfied with the completed questionnaires, please click "Submit ALL Questionnaires" below.
After the questionnaire have been submitted, you will be able to view/save/print the completed questionnaires (PDF format) on the confirmation page.

Entering your name below constitutes your electronic signature on all questionnaires.
	Check this box if signed by Patient OR
[Signature of Patient/Parent/Conservator/Guardian]	[If signed by other than Patient, indicate relationship]

Submit ALL Questionnaires OR Go Back to Questionnaire: