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  Preanaesthesia quaestionnaire

  The Questionnaire is designed to assist the doctors who will be
  taking care of you (or your child). It willl help us to learn more about
  your health (or the health of your child).Please fill it out to as
  completely as possible and return it to the reception desk.

 

  Name :        
  Email :        
 
  Age :        
  sex :         Male    Female
  Occupation:        
  Home Address:
  Home Phone:  
  Local Phone:  
  Referring Physician  
 (Surgeon)  
  Reason :  
(type of operation)
  Date of Operation :  
  How would you rate overall health?
   Excellent       Good      Fair      Poor 
  Has there been a recent change in your health ?.
     Yes       No      Comment  
  How physically active are you?(Please Select)
   Very Active        Somewhat Active       Not Active   
     (no restrictions)            (walk upstairs)          (unable to walk)
  Previous Hospitalisation
    Date                        Hospital Problem(s)             Type of operation              Type Of Anaesthesia
 1          
 2          
 3          
 4          
 5          
Do you have or have you ever had any of these problems :(please tick)
 Heart attack or heart failure            
 Stroke                                                     
 Kidney or bladder problem            
 Liver problem or hepatitis                         
 High blood pressure                      
 Diabetes                                                   
 Bleeding problem
 Cancer 
 Seizure or Epilepsy                       
 Rheumatic Fever                                    
 Arthritis                                        
 Lung problems(e.g. Pneumonia,asthama)  
 Other                                
   Please name any medicine that you are presently taking, include all prescription and non-prescription drugs (even aspirin)
    Type of medication                           Dosage(amount)                        Number of times taken each day
  1            
  2            
  3            
  4            
  5            
  Are you Allergic to,or have you had unusual reactions following the use of adhesive tapes,medicine,or drugs ? Please list the item and the type of reaction you experienced.
  Have you ever taken steroids such prednisone or cortisone?
     Yes       No     If so,when  
  Do you have any of the following:(Please select)
   False teeth    Capped teeth   Loose teeth   Or teeth that need dental care 
  Specify 
  Have you or any of your close relatives encountered problems or complications with anaesthesia?
     Yes       No      
If so, what  
  At the present time,do you have?(Please Tick Appropriate Boxes)
Chest Pain                                     Blackout or periods of dizziness      
Palpitation or irregular heart beats  Pain in your legs with exercise        
Ankle swelling                                Shortnessof breath at night              
Shortness of breath with exercise    Chronic cough or sputum (phlegm) 
Blood in your sputum                     Black or tarry stools,diarrhea          
Frequent nausea and vomiting        Temporary loss or blurring of vision 
Facial weakness, numbness            Burning with urination or frequent
       Urination                                       
Arthritis or joint pain  Back pain                                     
Excessive bleeding following 
       minor cuts or dental surgery                              		 Recent weight loss                          
Difficulty in walking                      Pregnancy                                    
   Have you had any recent problems with (Please Tick)
   Cold     Flu     Bronchitis     Laryngitis     Sore Throat     Fever 
  Do you smoke
     Yes       No      How many years        Packs per day  
  Do you drink alcoholic beverages?
     Yes       No      Drinks per day   
  Do you wish to discuss the possible complications of anaesthesia?
     Yes       No  
  Questions for the anaesthsiologist:
  

                                     
                                          

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