Anesthesia Form

Anesthesia Questionnaire

Scheduled Anesthesia Technique: Light General Anesthesia

Living alone yesno
Back home accompanied yesno

Medical History :

Have you had surgery? yesno
If so, which and when? :
Did you have any anesthetic or surgical problems?:yesno
If so why ? :
Do you take medications regularly ?yesno
If so, which ones ? (Name, frequency and dose) :
Do you smoke ?yesno
If so, how many cigarettes a day ? :
Are you drinking regularly or occasionally alcohol ?yesno
If so, how much and how often? :
Do you have allergic reactions ?yesno
If so, which ones? :

Do you have :

Removable dental prostheses ?yesno
Fixed dental prostheses yesno
Of loosened teeth ?yesno
Do you wear contact lenses ?yesno

For women :

Do you think you're pregnant ? yesno
If so, how many weeks ? :
Are you taking the pill ?yesno

Bleeding And Transfusion:

Do you take aspirin, sintrom, plavix or other anticoagulant medication ?yesno
Do you get easily a bruise or do you bleed easily from the nose ?yesno
Do you have known coagulation problems in your family ?yesno
Have you ever received a blood transfusion ?yesno
If so, why and when ? :

Diseases :

Do you suffer or did you suffer: :
Of Heart disease ?yesno
Of Blood pressure too high ?yesno
Of diabetes ?yesno
Of asthma ?yesno
Of hepatitis or other liver disease ?yesno
Of a gastric ulcer, gastritis ? yesno
Of a Thyroid Disease ?yesno
Of Eye disease ?yesno
From a transmissible disease ?yesno
Another disease ? yesno
If so which one ? :

Cardiorespiratory function :

Are you out of breath by going one level upstairs on foot ?yesno
Do you suffer from pain in the chest (angina pectoris) during exercise, nervousness, after the meal or because of cold ?yesno
Should you sleep with your head raised so as not to be out of breath ?yesno
Do you suffer from palpitations ?yesno
Do you wear a pacemaker ?yesno
Do you wear an artificial valve ?yesno

If you are taking medication, your treatment should be continued on the day of your examination unless the anesthesiologist advises differently. In some cases, temporary discontinuation of certain medications will be required a few days before the exam (eg Plavix, Cardioaspirin, Asaflow and Sintrom as well as some antihypertensive and antidepressants).
It is also essential to remove the nail polish and any piercings.

A document relative to free and informed consent must be completed and signed for the day of the examination.Obtain the document.

I hereby declare that all the information given above is true.