Anesthesia Form

Anesthesia questionnaire

What is its use?

This questionnaire allows you to assess your state of health before digestive endoscopy. It is part of the preoperative assessment and is strictly confidential. By affixing your signature on this form, you also give the authorization for the anesthesia. You can complete the document yourself or have it completed by a representative. More information about anesthesia.



    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.