PRE-SEDATION SCREENING

Name of person giving information : __Suganthi

chandrasekaran___________________
Relationship to patient :

parent

Allergy or adverse reaction to eggs, soy, sedatives, anesthesia :

no

Estimated weight : ___17 kg___________

Date of study : 10-Dec-2015______________
ist_____________

Time of study : __8 pm

Procedure being performed : ___Placing the cath line in the

neck______________________________
Reason for study/test : _____to enable ldl apheresis
______________________________________
Respiratory :

none

Neuromuscular : none
Cardiac : none
Cardiologist : ___apollo hospital, delhi___________ Last seen : ___Sept
2014____________
Genitourinary : none
_____________

kidney disease

dialysis

UTI

reflux

LMP

Gastrointestinal : none abnormal swallowing copious secretions reflux

vomiting IBD
G tube / J tube
colostomy/ileostomy
liver disease/jaundice
Developmental : none premature genetic disorder ADD/ADHD autism
PT/OT cognitive delays
learning disabilities
developmental concerns
Endocrine : none

diabetes (type I or type II)

thyroid disease

steroid use

Hematology/Oncology : none
anemia
bleeding disorder
cancer (dx date__________ last chemo ___________)
Immunizations up to date :

yes

no

Recent illness ( < 2 weeks) or exposure to communicable diseases :

no
Family history :
conditions

none bleeding disorders anesthesia complications

yes

medical

PRE-SEDATION SCREENING
Metalic implants or implantable devices :
Other appointment same day :
no

yes

Parents told to give medications : yes

NPO instructions :

solids _____________

yes

no

no

other

Labs ordered :
no

clears______________

yes