APASS Questionnaire | Children's of Alabama

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APASS Patient Questionnaire

Full Name of person completing questionnaire

Surgeon:

Date of Surgery:

Procedure:

PATIENT'S LEGAL NAME (First Name):

Middle Name:

Last Name

Preferred Name:

(Patient's) Date of Birth:

Parent/Legal Guardian:

Parent/Legal Guardian Contact Phone Number(s) (including area code):

Provider (PCP) Office Number:

(Patient's) Primary Care Provider (PCP)

Primary Care Provider (PCP) City:

Patient's current MEDICATIONS: (including nebulizer, aerosol, herbal, over-the-counter):

Patient's ALLERGIES: (Ex. none, foods, drugs or latex):

Patient's Birth Hospital

How far along in the pregnancy was the mother when the baby was born? (month/weeks/days)

Patient's Birth Weight

How long did the patient stay in the hospital at birth?

At birth was the patient:

Full Term (greater than or equal to 37 weeks)

Premature (less than 37 weeks)

twin or multiple birth

vent at birth

oxygen at birth

apnea monitor at birth

discharged home on oxygen

discharged home on monitor

Patient's Birth complications:

Has the patient ever had general anesthesia (been put to sleep)?

Yes

No

Don't Know

None

Surgeries:

Did the patient have any problems with being put to sleep or waking up from the anesthesia?

Yes

No

Don't Know

None

If YES, then please explain:

Have you ever been told the patient was difficult to intubate?

Yes

No

Don't Know

None

If YES, then please explain.

Has the patient ever had a high fever with anesthesia? (ex. malignant hyperthermia)

Yes

No

Don't Know

None

If YES, then please explain.

Does the patient have any problems opening the mouth or moving the head/neck?

Yes

No

Don't Know

None

If YES, please explain mouth, neck or head problems.

Does the patient see any speciality doctors (cardiology, pulmonary, neurology, endocrinology, etc)?

Yes

No

Don't Know

None

If YES, please list specialty doctor's names

If the patient has any existing conditions not in the list, please list here

Implantable Metal Devices

Baclofen Pump

Bone Anchored Hearing Aid (BAHA)

Cochlear Implant

Pacemaker

Vagal Nerve Stimulator (VNS)

Other

None

If Other, please specify:

Check if the patient uses:

Alcohol

Tobacco Products

Recreational Drugs

PATIENT RECENT ILLNESS

1. Has the patient had a cold or upper respiratory tract infection in the last 14 days?

No

Yes

2. Has the patient had a stomach virus in the last 7 days?

No

Yes

3. Has the patient had COVID-19, bronchitis/bronchiolitis, croup, pneumonia or flu in the last 4-6 weeks?

No

Yes

4. Has the patient taken steroids (Cortisone, Prednisone, Prednisolone, Orapred) in the last 6 weeks? (Do not include daily inhaled steroids)

No

Yes

5. Has the patient been seen in an Emergency Room in the last 2 months?

No

Yes

6. Has the patient been admitted to the hospital in the last 3 months?

No

Yes

If YES to questions #1-6, please explain:

FAMILY HISTORY (Patient blood relatives)

1. Is there a family history of serious complications or unexpected death related to anesthesia?

No

Yes

Unknown

patient is adopted or in DHR custody/foster care

2. Is there a family history of dangerously high fevers associated with anesthesia (Malignant Hyperthermia)?

No

Yes

Unknown

patient is adopted or in DHR custody/foster care

3.Is there a family history of sensitivity to anesthesia medications (Pseudocholinesterase Deficiency)?

No

Yes

Unknown

patient is adopted or in DHR custody/foster care

4. Is there a family history of muscle disease (Muscular Dystrophy, etc.)?

No

Yes

Unknown

patient is adopted or in DHR custody/foster care

5. Is there a family history of bleeding disorders (Hemophilia, Von Willebrand Disease, etc)?

No

Yes

Unknown

patient is adopted or in DHR custody/foster care

6. Is there a family history of blood disorders (Sickle Cell Trait, Sickle Cell Anemia, Thalassemia, etc)?

No

Yes

Unknown

patient is adopted or in DHR custody/foster care

7. Has anyone living in the patient’s house had COVID-19 in the last 4 weeks (or are they awaiting COVID-19 test results)?

No

Yes

If YES for questions #1-7, please explain:

IF the patient is in DHR custody, please provide DHR contact information.

DHR County:

Caseworker's Name:

Caseworker's Contact phone #s (include area code):