MALIGNANT HYPERTHERMIA SCREENING

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Patient Name: _________________________________ DOB: _________

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Please answer the following questions to the best of your knowledge:

Do you have a personal history of Malignant Hyperthermia? YES / NO

Has any one of your blood-relatives been diagnosed with Malignant Hyperthermia? YES / NO

Has any one of your blood-relatives suffered an unexpected death following general anesthesia? YES / NO

Has any one of your blood-relatives suffered an unexpected death following exercise? YES / NO

Do you have a personal history (or family history) of a muscle or neuromuscular disorder? YES / NO

Have you ever experienced high temperatures following serious exercise? YES / NO

Have you ever experienced high temperatures following general anesthesia? YES / NO

Do you have a personal history of muscle spasms? YES / NO

Have you ever passed very dark or chocolate colored urine? YES / NO

Should there be a suspicion you are at a high risk for Malignant Hyperthermia (MH), you may be sent for genetic testing and/or caffeine-halothane contracture testing BEFORE surgery.

The physician and anesthesia provider will customize an anesthesia plan that minimizes your risk of exposure to MH triggering agents.

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Patient Signature: ____________________________________ Date: _________

Reviewed By: ________________________________________ Date: ________

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