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Adult Anesthesiology Questionnaire Mobile App

We have developed the Adult Anesthesiology Questionnaire mobile app in order to make the process of preparing you for your outpatient surgery more efficient. Both a nurse and the anesthesiology team will review this information with you. They will do their best to answer whatever questions that you may have. We thank you very much for your time. A GoCanvas account can be specified as being HIPAA compliant. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Individual apps in the GoCanvas Application Store can easily be made HIPAA Compliant. If you have any questions or need assistance you can contact our Sales team to help you at Sales@GoCanvas.com. If you would like to enable HIPAA on your GoCanvas account please follow the instructions below: 1. Log onto your Account 2. Click “My Account” in the top right corner of the screen 3. Click “Customize” on the left 4. The third option is for HIPAA Compliance, click “Edit” on the right 5. Check the “Enable HIPAA Compliance” box and select “Save”

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Adult Anesthesiology Questionnaire Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Patient Name:

  • Ico date

    Date:

  • Ico date

    DOB:

  • Ico integer

    Age:

  • Ico dropdown

    Do you have any specific concerns regarding your anesthesia?

  • Ico multiline

    Please tell us about them.

  • Ico multiline

    What is your surgeon going to do for you?

  • Ico dropdown

    What gender are you?

  • Ico decimal

    How much do you weigh?

  • Ico decimal

    How tall are you?

  • Ico dropdown

    Do you have a regular physician?

  • Ico textbox

    Name/Title

  • Ico textbox

    Phone

  • Ico multiline

    Clinic Name/Address

  • Ico dropdown

    Do you have a heart doctor?

  • Ico textbox

    Name/Title

  • Ico textbox

    Phone

  • Ico multiline

    Clinic Name/Address

  • Ico statictext

    Please list any prescription and /or non-prescription medications including vitamins, supplements...

  • Ico checkbox

    I am not taking any medication

  • Ico dropdown

    Have you taken aspirin containing products within the last 2 weeks?

  • Ico dropdown

    Have you taken steroid or cortisone type drugs within the last year?

  • Ico dropdown

    Do you take antibiotics prior to dental work or any other procedures?

  • Ico multiline

    Please write down the name and address of your pharmacy:

  • Ico textbox

    Name of Medication

  • Ico textbox

    Dose (Strength)

  • Ico multiline

    How often taken (e.

  • Ico dropdown

    Are there any medication to which you have had an allergic reaction or unpleasant side-effects?

  • ...and More!

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