Dear Patient: Please complete this health history questionnaire to the best of your ability. Your Anesthesiologist will review it prior to your Pre-Anesthesia Clinic appointment.

Kemptville District Hospital collects the information you provide in this form under the authority of the Freedom of Information and Protection of Privacy Act, the Personal Health Information Protection Act and the Public Hospitals Act. By completing this form you are consenting to the hospital’s collection of the personal health information you provide on this form. The Hospital cannot guarantee that your electronic completion or submission of this form is secure and confidential. If you choose to complete or submit this form to the Hospital using electronic mail or the weblink provided, or both, each of which may be unsecured, you agree to:

  1. assume all risks associated with doing so, including a risk of unauthorized collection, use or disclosure of the information contained in this form; and
  2. waive all claims you or your dependants may have against the hospital arising from your use of electronic mail or the weblink provided or both; and
  3. release the hospital from any liability or losses accruing to you or your dependants as a result of your use of electronic mail or the weblink provided or both.

You have the option to complete and submit this form by choosing one of the following alternatives:

  1. You may print a copy of this form, complete, scan it and send it electronically to the hospital at ​By choosing this option you agree to assume all risks associated with unsecured electronic transmission, waive all claims against the hospital associated with such transmission and release the hospital from all liability or losses accruing to you and your dependants as a result of such transmission; or
  2. You may participate in a telephone conversation with a hospital representative who will collect the information. To schedule a telephone discussion, please call (613) 258-6133 extension 164 for hip/knee surgery, or extension 423 for all other surgeries.

Find a printable version of the form here.

    Required fields are indicated with an asterisk (*)

    Date of birth *

    Proposed date of Surgery


    Do you have allergies to:






    Do you have:

    Any heart problem? (e.g., heart attack, murmur, angina, blockages, angioplasty, stent, valve problems, irregular heartbeat, heart surgery, heart failure).

    High blood pressure?

    Chest pain or breathlessness after climbing 2 flights of stairs?

    A pacemaker or an implantable defibrillator?

    An artificial heart valve?

    Any other heart issues?

    Do you smoke tobacco of any kind? (e.g., cigarettes, cigars, pipes).

    Blood Problems

    Have you ever been treated for:

    Anemia (low blood count)?

    Blood clots (in your lungs, legs or other)?

    A bleeding disease or problem?

    Do you have any personal or religious reasons for refusing to have any blood products given to you?


    Do you have:

    Emphysema, chronic obstructive pulmonary disease (COPD) or chronic bronchitis?


    Sleep apnea? (diagnosed by a physician)

    A breathing machine to help you sleep?

    Inhalers (puffers)?

    Oxygen at home to help you breathe?

    A problem lying flat for at least 30 minutes because of difficulty breathing?

    Or ever had, shortness of breath for which you have been admitted to hospital within the last 2 months?


    Do you have/have you had:

    Memory problems or confusion?

    A history of extreme confusion after an operation?

    A stroke or stroke- like symptoms in the past?

    Any aneurysm?

    Epilepsy or convulsions?

    Fainting spells?

    Other important medical information

    Do you have stomach ulcers, heartburn or a hiatus hernia?

    Have you had radiation treatment? Or been diagnosed with Cancer?

    Are you diabetic?

    Are you on dialysis?

    Do you have kidney disease?

    Do you have liver disease?

    Do you take Aspirin (ASA) regularly?

    Are you on a prescription for blood thinners? (e.g., warfarin, coumadin, plavix, dabigatran, rivaroxaban)

    Do you have family (blood relatives) who have had serious problems following an anesthetic?

    Have you had serious problems following an anesthetic (e.g., malignant hyperthermia)?

    Do you have trouble opening your mouth, jaw or moving your neck?

    Do you have a chronic pain disorder?

    Is there a possibility that you could be pregnant?

    Do you have arthritis?

    Do you use any street drugs?

    Do you have a hearing impairment or wear a hearing aid?

    Do you have any loose teeth or dentures?

    Has anyone ever told you that you had a difficult airway?

    Have you ever had back surgery?

    Discharge Planning and Mobility

    Do you use a wheelchair, walker, cane, scooter or other aid?

    Do you have problems with your balance?

    Do you have someone available to stay with you overnight and help care for you?

    Do you live in a retirement home, boarding home or long term care facility, or other?