PRE-ANESTHESIA QUESTIONAIRRE
INSTRUCTIONS: PLEASE INDICATE BY A CHECKMARK YOUR ANSWER TO EACH QUESTION. THESE
ANSWERS WILL GREATLY HELP US TO GIVE YOU THE BEST POSSIBLE CARE DURING YOUR
PROCEDURE. IF YOU DO NOT KNOW AN ANSWER, PLEASE INDICATE BY A QUESTION MARK (?). IF
THERE ARE MULTIPLE ANSWER, PLEASE CIRCLE THE APPROPRIATE ONE, BE SPECIFIC, EXPLAIN IF
NECESSARY.