Pre-Op Questionnaire

Anaesthesia Assessment – Patient Questionnaire

Anaesthesia Specialist Pre Op Questionnaire

Please complete the questionnaire below. Please answer all questions as accurately as possible. All information is sought to minimise your risk.

Male or Female

Health Questionnaire

3. Do you suffer from, or have you ever suffered from, the following:
Chest pains /tightness or angina
Shortness of Breath
Previous Rheumatic Fever
Asthma
Previous heart attack
Emphysema or bronchitis
Palpitations
Tuberculosis
Heart murmur
Obstructive sleep apnoea
High blood pressure
Persistent cough
Artificial heart valve or pacemaker
Stroke or seizures
Hiatus hernia / heartburn / indigestion
Jaundice or hepatitis
Diabetes - oral medication
Thyroid disease
Diabetes - insulin dependent
Previous DVT or lung embolus
Kidney Disease
Bleeding or clotting disorder
Rheumatoid arthritis
Motion Sickness

4. Do you smoke?

5. Do you drink alcohol?

6. Risk of exposure to hepatitis?
8. Please list previous surgery, including year and hospital if known:
9. What medications (including herbal) and/or drugs are you taking?
10. Do you have problems with opening your mouth? (eg. previous jaw problems)
11. Have you been told of any difficulties during your anaesthetic?
12. Do you have dentures, partial plate, capped or loose teeth?
13. What physical activities do you take part in on a regular basis? (tick those that apply)
14. How may flights of stairs can you climb without getting out of breath?
15. My activity is restricted by:
16. Do you allergies to medications, tablets, plasters, food LATEX or any other substance?
If "yes" please specify:
17. Are there major illnesses, to your knowledge, among your blood relatives?
e.g. diabetes, muscular dytrophy, malignant hyperthermia
If "yes" please specify:
18. Have you or any of your family had problems with an anaesthetic?
19. Do you suffer from any other condition, not covered elsewhere, that you feel we should know about?
20. Do you have any concerns or questions about your anaesthetic?
21. Do you wish to see your anaesthetist before coming to hospital?
22. WOMEN ONLY - Are you or could you be pregnant?

Signature

I give permission for my / my child's medical records and investigation results to be accessed for the purpose of assisting in my anaesthetic.
The above details have been completed by:
If you have urgent queries, please contact your anaesthetist at his/her rooms or your surgeon.
If your anaesthetist beleives there are significant risks identified in this questionnaire, he/she may contact you to make an appointment before surgery.
Please bring all your medications with you to the hospital.