Pediatric Pre-Anesthesia Questionnaire
What a pediatric pre-anesthesia questionnaire asks, with sample questions on medicines, past anesthesia, and birth history.
A pediatric pre-anesthesia questionnaire records a child's medicines, allergies, past anesthesia, birth history, and needs before surgery or a procedure. The questions on this page are built from questionnaires used at Stanford Medicine Children's Health and Children's of Alabama.
Pediatric pre-anesthesia questionnaire, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a pediatric pre-anesthesia questionnaire in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample pediatric pre-anesthesia questionnaire questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- What is your preferred language?Contact
- How should the care team contact you?Contact
- Which medicines does your child take?Medicines
- Does your child take herbal or over-the-counter products?Medicines
- Does your child have any food or drug allergies?Allergies
- What happens during your child's allergic reaction?Allergies
- Has your child had surgery or anesthesia before?Anesthesia history
- Has a family member had problems with anesthesia?Anesthesia history
- Was your child born prematurely?Birth history
- Did your child stay in the NICU after birth?Birth history
- Does your child have a developmental delay?Child's needs
- What should the anesthesiologist know about your child?Child's needs
These are examples to read, not a form to fill in.
Pediatric pre-anesthesia questionnaire: FAQ
What does a pediatric pre-anesthesia questionnaire ask?
The sample questions on this page are based on pre-anesthesia questionnaires from Stanford Medicine Children's Health and Children's of Alabama. This page groups them into six areas: contact, medicines, allergies, anesthesia history, birth history, and child's needs.
Who fills in a pediatric pre-anesthesia questionnaire?
A parent or legal guardian, before the child's procedure. The Stanford questionnaire asks families to complete it and bring it to the appointment.
Why does the hospital ask these questions?
The Stanford form says the answers help the care staff learn the child's health history and needs on the day of the procedure.
Does it ask about birth history?
Yes, the Children's of Alabama form asks whether the child was born full term or early. It also asks the weeks of pregnancy at birth and about any NICU stay, oxygen, or ventilator.
Does it ask about family anesthesia problems?
Yes. Both forms ask whether a family member has had problems or unusual reactions with anesthesia.
What happens after the pediatric pre-anesthesia questionnaire is completed?
The anesthesia team reviews the answers before the procedure. AI Doctor only collects them, and the anesthesia plan stays with the care team.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
