Personal Information
How tall are you?
How much do you weight?
Do you have difficulty opening your mouth wide or limited neck movement?YesNo
Have you had any recent anaesthetics? (Including at the dentist)YesNo
If yes, When was the last one?
Do you have any questions, worries or concerns about the anaesthetic that you would like to talk to us about?YesNo
If yes, What are they?
Do you have or have you ever had / Does your child have or ever had:
High blood pressure?
YesNo
Chest pain or Angina?
Heart attack?
Any other heart condition?
Lung problems needing hospital?
Troublesome shortness of breath?
Chronic bronchitis?
Asthma?
Do you (or your child) use puffer (e.g Ventolin)?
Sleep Apnoea?
Other lung, chest or breathing problem?
Diabetes?
Do you use isulin?YesNo
Do you take diabetic tablets?YesNo
Controlled by diet only?YesNo
Hayfever?
Epilepsy or Fits?
Stroke?
Black outs or Fainting?
Blood clots or bleeding disorder?
Chemotherapy / Radiotherapy?
Anaemia?
Previous blood transfusion?
Kidney Condition?
Hepatitis or Liver condition?
Has your doctor ever prescribed for you (your child) Prednisone, Cortisone or other steroids?
Is there a condition that runs in the family? e.g. thalassaemia, muscle dystrophy, etc.
Do you (or your child) have any other conditions not mentioned above? e.g. hormone therapy, poor teeth, athritis?
Are you (is your child) available at short notice for admission to hospital (less than one week)?
Adult Patients
Do you smoke?
Do you use recreational substances, e.g. marijuana?
Do you drink alcohol?
Do you have someone to stay with you the night after you leave hospital?
Do you have someone to collect you from hospital?
Children
Was your child born premature?
Has the patient completed this questionnaire themselves?
If No, what is your relationship to the patient?
Please answer the questions by ticking the appropriate box and give any necessary details in the space provided.
Do you (does your child) have any health problems other than the planned surgery?
If yes, what are they?
Have you (has your child) been in hospital for any health problems including previous surgery?
If yes, what are they? When were they?
Have you (has your child) seen a heart specialist in the last 5 years?
If yes, provide name and contact details
Do you (does your child) use a regular medications? (e.g. oral medications injections, puffers)
If yes, please list them below.
Name Of Medicine
Dose (How Much?)
How often each day?
Do you (does your child) have any allergies (especially to medicines, sticking plaster, food, Latex)
If yes, what are they? What reaction did you (your child) have?
Have you or any family member had a problem with an anaesthetic? (e.g. bad reaction)
If yes, what happened?
Have you (has your child) had any recent anaesthetic? (including at the dentist)
If yes, when was the last one?
Do you have any questions, worriesor concerns or concerns about the anaesthetic that you would like to talk to us about?
