NAVAL MEDICAL CENTER SAN DIEGO ADULT PREOPERATIVE ANESTHESIA WORKSHEET Modern anesthesia is very safe, but like any medical procedure, there are risks. Major problems, even death or major disability can occur even in the best situation; however, these are very rare. Before surgery, you will be interviewed by an Anesthesia Provider and at the time, the risks and benefits of the types of anesthesia will be fully discussed with you and a final choice of anesthetic will be made. Please feel free to ask questions about your anesthesia care. Please complete and sign the following questionnaire. This will be reviewed by the Anesthesia staff and will be very helpful in determining the most appropriate anesthetic for you. NAME OF PATIENT: PHONE NUMBER: AGE GENDER Male Female HEIGHT inches WEIGHT lbs PLANNED SURGICAL PROCEDURE: Planned Date of Procedure: PAST SURGERIES & ANESTHESIA Date Procedure Anesthesia (General, Spinal, Epidural, Sedation, etc.) Problems, if any PLEASE ANSWER ALL QUESTIONS TO THE BEST OF YOUR KNOWLEDGE. Has anyone in your family had significant problems with anesthesia (death, high fever/malignant hyperthermia, delayed awakening)? Have you ever had a breathing tube placed? If yes, were you told it was difficult? Is there any possibility that you are or might become pregnant before the procedure? Have you had cold symptoms (cough, runny nose, fever, difficulty breathing) in the past 4 weeks? HAVE YOU EVER HAD THE FOLLOWING? If yes, please explain in the space provided. Lung or breathing problems? (COPD/emphysema/asthma/pneumonia/severe or recurrent bronchitis) Tobacco use? Average packs per day X years Quit? Obstructive Sleep Apnea (OSA)? CPAP/BiPAP machine? Heart problems (heart attack/chest pain/irregular heartbeat/murmur/heart failure/loss of consciousness/defibrillator/ pacemaker)? Vascular problems (peripheral arterial disease, stent/graft surgery)? High Cholesterol? Kidney problems (renal failure/dialysis/stones)? Peritoneal Dialysis Gastrointestinal problems (heartburn/reflux/ulcer/diarrhea)? Liver problems (hepatitis/cirrhosis/jaundice)? Diabetes? Insulin? Gestational Diabetic? Thyroid problems (hypothyroid/hyperthyroid/graves)? Steroid use in past 6 months? Blood disorder (sickle cell/bleeding disorder/prior transfusion)? Cancer? Type: Chemotherapy? Type of medication: Radiation? Neurologic problems (weakness/nerve injury/seizure/stroke/recurrent severe headaches)?
Mental health issues (depression, anxiety, PTSD, bipolar, etc.) Muscle/bone/joint problems (arthritis/weakness/muscular dystrophy)? Skin problem (current infection/mrsa)? Eye problem (glaucoma)? Other medical problems? MISCELLANEOUS QUESTIONS Have you had surgery at Naval Medical Center San Diego in the past year? On the day you are coming in for your procedure are you scheduled to have any other procedures, labs drawn or other tests? If yes please explain On your day of surgery, is there any reason that you would not be able to come in at 0500-0630? If yes, please explain: Females only: All females receive a pregnancy test on the day of surgery unless they are post-menopausal or have had a hysterectomy. Please check if this applies to you. Post-menopausal Hysterectomy POST-OPERATIVE NAUSEA AND VOMITING (PONV) SCREENING # OF POINTS: + 1 = (all start with one point) Yes (1) No Female Gender? (1) Do you smoke? Yes (1) No History of post-operative nausea or motion sickness? OBSTRUCTIVE SLEEP APNEA (OSA) SCREENING # OF YES ANSWERS: Do you SNORE loudly or have you been diagnosed with SLEEP APNEA? (Louder than talking or loud enough to be heard through closed doors) Do you often feel Tired, fatigued, or sleepy during daytime? Has anyone OBSERVED you stop breathing during your sleep? Do you have or are you being treated for high blood PRESSURE? AGE over 50 years old? Male GENDER? Next two Questions below completed by PAC Staff NECK circumference > 15.75 inches? (Neck Circumference: inches) BMI more than 35? BMI (Height: inches / Weight: lbs.) MULTI-DRUG RESISTANCE ORGANISM (MDRO) SCREENING # OF YES ANSWERS: Have you been told by a physician that you have had any Multi Drug resistant organism infection or colonization? Have you recently been a patient in a trauma unit, Skilled nursing facility or been in combat theater of operations and have an open wound? Do you have a skin or soft tissue infection? Are you a dialysis patient or have you been hospitalized within the last 30 days? Allergies and Medications to Avoid and Adverse Reactions to each Medication: Allergies? If yes, please list what you are allergic to and the reaction. 1. 2. 3. 4. 5. Latex Allergy?
Current Medications: List all medications you are taking, include over-the-counter (e.g., aspirin, antacids, vitamins and herbals). The records in the computer generated list are not always up-to-date. It is very important for the surgeon and the anesthesia providers to have a complete list of the current medications you are taking in order to provide the safest care possible. If you do not know all of the medications you may call your outside physician or take this page of this form home, complete and fax it to us prior to the day of your procedure. Fax# 619-532-8663. Thank you! Medication Dosage # of time you take per day or state as needed 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. The previous statements are true to the best of my knowledge. Patient Signature (or Parent/ Legal Guardian) Date:
ADULT PREOPERATIVE INSTRUCTIONS 1. Your surgery/procedure/anesthetic is scheduled for. Your surgeon is. 2. Complete all ordered labs, x-rays, and diagnostic tests, today, unless otherwise instructed. 3. You will receive an automated message by 4 PM one business day prior to your surgery. If you do not receive a call by 4:30 PM please call (619) 532-6844 (option 1) or (619) 532-6335 for your check-in time. On weekends and holidays, please call (619)532-9000 for your check-in time. 4. Do not eat, drink alcohol, smoke, chew tobacco, chew gum or eat candy after midnight the night before your surgery. 5. You are encouraged to drink clear liquids up to 2 hours before your check-in time. Clear liquids: Clear apple juice, Gatorade, 7-up or Sprite or other sports drink. You may also drink black coffee (No creamers). In summary, do not eat after midnight the night before your surgery and do not drink 2 hours before you are to check- in for Surgery. 5. Take a shower and wash the area of surgery twice the night before and once the morning of surgery as instructed with: Antibacterial soap 2% HCG Cloth N/A Hibiclens betadine Other 6. Do not wear makeup or nail polish. (DO NOT APPLY LOTION, PERFUME, COLOGNE, SCENTED DEODORANT, OR POWDER AFTER SHOWERING. DO NOT SHAVE AREA OF SURGERY). 7. Take regularly scheduled medications with a sip of water the morning of surgery unless otherwise instructed by anesthesia and/or your surgeon. 8. Do not take aspirin, aspirin containing products or anti-inflammatory medication (Motrin, Advil, Naprosyn, Ibuprofen, Celebrex ) for 2 weeks prior and during post-operative care unless otherwise directed by my surgeon (excluding Ophthalmology patients). Patients, who have had heart stents, please consult your cardiologist before stopping any medication. 9. Complete all pre-op preparations as instructed by staff in the surgical clinic: Colyte Enema Fleets Phosphosoda Magnesium Citrate Other 10. Bring your Military ID Card for identification purposes or any other necessary paperwork. If you have an advanced directive, please bring it on the day of surgery. If you would like information about advanced directives, you may obtain this information at the front desk or at the NMCSD legal department. 11. Bring crutches, braces, or support garments as directed by your surgeon. Bring containers and solutions for contact lenses, glasses, dentures, hearing aids, and a small bag with toiletries if staying overnight. 12. Do not bring jewelry (including wedding bands and body jewelry/piercings), money, credit cards or other valuables. If you choose to keep valuables or prosthetics such as glasses, dentures, or hearing aids, you assume liability and can not to hold accountable the U.S., the Dept. of the Navy, NMCSD, and/or any employee or agents of the foregoing for any claim that might arise as the result of loss of such valuables or personal effects. 13. Only ONE person is allowed to accompany you into the pre-operative area. Children under 12 years old are not permitted. 14. You must have a responsible adult to take you home and stay the night after being discharged. Active duty members MAY NOT spend the night in the barracks or on the ship. 15. Active Duty: A signed AND approved copy of your Command Authorization for Surgery form is required to be faxed no later than noon the day before surgery to 619-532-8363. (Bring a copy on your surgery day.) Confirm receipt by calling 619-532-6530. 16. Please call your surgeon if you develop a fever, rash, cold, or other illness between now and my scheduled date of surgery. 17. Check-in day of surgery at the Main Operating Room surgery check-in located on the 4 th floor of building 1. Note: If you are a female, upon checking in, you may be asked to provide a urine specimen to ensure that you are not pregnant. 18. If you have any other questions, please contact your surgical clinic. I acknowledge I have read and understand the preoperative instructions as stated above. Not following these instructions may result in case delay or cancellation! Patient / Legal Guardian Signature / Date Nurse/Corpsman/Medical Technologist Signature / Date
Explanation of Admission forms you will sign on the day of your procedure: AUTHORITY TO ADMIT: The registration form provides the hospital information about what medical service is admitting you, your significant other, the name, address, phone number, next of kin for emergency contact, and sponsor s information. GENERAL CONSENT TO TREATMENT: Gives providers at NMCSD permission to treat you, contains cost of medical care and food. The current cost of medical care is $18.80 per day for dependents, there is no charge for active duty and retirees. PRIVACY ACT STATEMENT: The Privacy Act Statement states that information in your health record will be kept private, and the information is released only on a need to know basis. ADVANCED DIRECTIVES AND PATIENT RIGHTS ACKNOWLEDGEMENT: Please let us know if you have or have not executed an Advanced Directive. If you have an Advanced Directive, bring a copy with you on the day of surgery/ procedure or day of admission. Please let us know if you do or do not wish to execute an Advanced Directive at this time. Information about your admission can be restricted; this includes information about your presence at NMCSD. Please let us know if you do or do not request this restriction. It s your right to make healthcare decisions. Help us honor those rights by providing us with your medical decisions in advance. The following explains your rights to make healthcare decisions and how you can plan what should be done when you can t speak for yourself. Federal law requires us to give you this information; we hope this will help you make informed decisions regarding your medical treatment. What is an Advanced Directive? Advanced Directive is a general term that refers to your oral and written instructions about your future medical care, in the event that you become unable to speak for yourself. It provides GUIDANCE to your family, friends, and healthcare providers when you can no longer make your wishes known. The California Advance Health Care Directive is a valid legal document for you to use. You may change it or use another form. It spells out the patient s wishes with regard to withholding or withdrawing various types of medical treatments. Who decides about my treatment when I am able to make decisions? Your doctor will give you information and advice about treatment. You have the right to choose. You can say Yes to treatments you want and you can say No to treatments you don t want even if the treatment might keep you alive longer. How do I know what I want? Your doctor must tell you about your medical condition and the different treatment options. Many treatments have side effects; you should discuss what is best for you with your doctor. Remember your doctor cannot decide for you! What if I am too sick to decide? If you can t make treatment decisions, your doctor will ask your closest available relative or friend to help decide what is best for you. Most of the time this works, however, sometimes everyone doesn t agree about what to do. That s why it is helpful if you say in advance what you want to happen if you can t speak for yourself. There are several kinds of Advanced Directives that you can use to say what you want and who you want to speak for you. NMCSD uses the California Advance Health Care Directive. Anyone 18 years of age and of sound mind can fill it out and you do not need a lawyer. Who can I name to make decisions for me when I am unable to do so? You can choose an adult relative or friend you trust as your agent to speak for you when you re too sick to make your own decisions. Please give this page to the patient to take home.
Explanation of Admission forms you will sign on the day of your procedure: What if my doctor feels they can t carry out my wishes? The doctor should transfer your care to another physician who can carry out your wishes. What if I change my mind? You can change or revoke an advance directive at any time as long as you can communicate your wishes either orally or in writing. Advance Health Care Directive This is a valid, legal document that lets you name someone to make healthcare decisions on your behalf should you become unable to speak for yourself. It lets you express your wishes regarding the use or withdrawal of lifesustaining procedures, allows you to express your wishes regarding donation of organs, and identifies your wishes concerning other health care decisions. Part 1 The California Advance Health Care Directive contains power of attorney for health care. Here you identify the name of the individual that will act as your agent. This person will make all healthcare decisions for you, not just life sustaining treatment. Make sure your agent is someone willing to carry out your wishes. Part 2 Allows you to give specific instructions about any aspect of your healthcare, including your wishes regarding the provision, withholding or withdrawal of life-sustaining treatment. Part 3&4 Allows you to express an intention to donate your organs and designate a physician to have primary responsibility for your healthcare. WITNESS Your signature must be witnessed by two individuals. Naval Medical Center Staff are prohibited from signing as your witness. Also, your two witnesses must NOT be involved in your medical care as a provider, mentioned in your will, or be a potential beneficiary to any part of your estate. Are there any other options? Yes, there are other options. The legal department can help you decide what option may be best suited for your needs. However, completing the California Advance Health Care Directive offers the best legal protection and insurance that your wishes will be followed. Whatever you decide, Naval Medical Center, San Diego, will not condition the provisions of healthcare or otherwise discriminate against any patient based upon whether an advance directive has been executed. What do I do with my Advance Directive once I have it? Keep the original singed document in a secure but accessible place. Do not put the original document in a safe deposit box or any other security box that would keep others from having access to it. Talk to your doctor, agent, clergy and family about your wishes concerning medical treatment. Give copies of the document to your agent and alternative agent(s), doctor(s), family, close friends, and clergy. If you enter a nursing home or hospital, have photocopies of your Advance Directive placed in your outpatient medical record and your inpatient medical record upon each admission. If you want to make changes to your Advance Directive after it has been signed and witnessed, you should complete a new document. Be aware that your Advance Directive will not be effective in the event of a medical emergency. Ambulance personnel are required to provide cardiopulmonary resuscitation (CPR) unless they are provided separate orders that states otherwise. For more information contact Naval Medical Center San Diego Legal Department Building 1, (619) 532-6475 Monday through Friday 8:00am-4:00pm Please give this page to the patient to take home.