Garcia-Miguel et al used a questionnaire to screen pediatric patients for significant disease prior to surgery.

NOTE: The wording has been changed from the original questionnaire and several items have been added (*).


Past history for the child:

(1) growth and development

(2) cardiac disease

(3) shortness of breath, cyanosis or other respiratory problems

(4) wheezing or history of asthma (*)

(5) kidney disease

(6) jaundice or liver disease

(7) easy bruisability or excessive bleeding (*)

(8) convulsions or seizures

(9) nerve or muscle problems

(10) allergies (*)

(11) any other medical condition

(12) hospital admissions

(13) previous operations (*)

(14) problems during any previous administration of anesthesia


Recent health history:

(1) exercise tolerance

(2) contact with anyone with an infectious disease in past month

(3) physician care during past month

(4) fever, rash, cough, cold or sore throat in past month


Family history:

(1) any problems during anesthesia

(2) any other familial disorders (*)



(1) current medications (*)

(2) vaccination status (*)


If female and at or beyond puberty:

(1) date of last menstrual period

(2) any chance of being pregnant


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