Pre Anaesthetic

Personal Details
Patient Name:
Email:
Phone:
Age:
Date of Birth
Height (cm):
Weight (kg):
Procedure Details
Surgeon:
Operation:
Date of Operation:
Hospital:
Other Details
Have you had a previous anesthetic?	Yes No
Did you experience any problems with the Anesthetic?	Yes No
If yes, what type of problems did you experience?	Nausea or Vomitting Breathing Problems Other - Please describe below:
Do you experience any Heart Problems?	Yes No
Do you experience Blood pressure problems?	Yes No
Have you ever had a heart attack, undergone bypass operation or had a stent inserted?	Yes No
Other? Please describe:
Have you had a Recent Cold? (last 2 weeks)	Yes No
Do you experience any Breathing Problems?	Yes No
If yes, do you have Asthma?	Yes No
Do you suffer from sleep apnoea or do you snore?	Yes No
Do you get short of breath walking around?	Yes No
Do you have Diabetes?	Yes No
If yes, do you take Insulin?	Yes No
Do you suffer from Heart Burn or Reflux?	Yes No
Do you Smoke?	Yes No
Do you have Thyroid Problems?	Yes No
Do you take Warfarin?	Yes No
Please list any allergies that you have.
Do you have any other medical problems which you have not listed above?
Please list your medications:

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