Pre-Anesthesia Questionnaire
What a pre-anesthesia questionnaire asks, with sample questions on allergies, medicines, health history, and past anesthesia.
A pre-anesthesia questionnaire records the patient's care team, allergies, medicines, health conditions, and past surgeries before an operation that needs anesthesia. Main Line Health calls its version an anesthesia health questionnaire.
Pre-anesthesia questionnaire, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a 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 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 the date of your surgery?Visit details
- Do you speak a language other than English?Visit details
- Who is your primary care physician?Care team
- Do you see a cardiologist or other specialists?Care team
- Do you have any medication allergies?Allergies
- Are you allergic to tape or bandages?Allergies
- Which medicines do you take, and why?Medications
- Do you take vitamins or herbal supplements?Medications
- Do you have sleep apnea or use CPAP?Health history
- Do you have type 1 or type 2 diabetes?Health history
- Which surgeries have you had, and when?Past surgeries
- Have you had any problems with anesthesia?Past surgeries
These are examples to read, not a form to fill in.
Pre-anesthesia questionnaire: FAQ
What does a pre-anesthesia questionnaire ask?
The sample questions on this page are based on the Main Line Health anesthesia health questionnaire. This page groups them into six areas: visit details, care team, allergies, medications, health history, and past surgeries.
Who fills in a pre-anesthesia questionnaire?
The patient, before the day of surgery. The Main Line Health form also asks where pre-op testing will be done and which pharmacy the patient uses.
Does it ask about every medicine?
The Main Line Health form lists each medicine, vitamin, and herbal supplement with its dose, directions, and reason. It asks patients who have a full medication list to send it with the form.
Which health conditions does it cover?
The Main Line Health form has checklists by body system, from neurological and heart conditions to breathing, metabolic, kidney, skin, and GI problems.
Is there a pre-anesthesia questionnaire template?
The sample questions on this page show a typical set. The Main Line Health form carries the names of Lankenau Medical Center, Bryn Mawr Hospital, Paoli Hospital, and Riddle Hospital.
What happens after the form is completed?
The surgical and anesthesia team reads the answers before the operation. AI Doctor only collects them and gives no advice about medicines or fasting.
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.
