Last update 2004

AS ANE 03: ANAESTHESIA QUESTIONNAIRE

Please bring with you on the day of your surgery.

• Have ever been admitted into hospital due to a medical problem?

yes no
• Have you ever had surgery? yes no
• Have you ever had anaesthesia? yes no
• What type of anaesthesia were you given?:
General Local Other
• Have you had any problems with anaesthesia for a surgical procedure, an exploratory procedure under anaesthesia or destinta? yes no
• Has any member of your family had any problems with anaesthesia? yes no
• Have you received a blood transfusion or any other blood derivative? yes no
•Do you have any congenital disease (present at birth)? yes no
• Are you suffering or have you suffered from any condition that requires medication? yes no
• What medication have you taken in the last SIX months? yes no
_______________________________________________
• Do you sel-medicate with analgesics, laxatives, tranquilisers, sedatives, diuretics, appettite suppressants or other medicines? yes no
• Are you currently suffering from a cold or nasal problem, rhinitis or nasal semptum diveation? yes no
• Have you had a pneumothorax (deflated lung)? yes no
• Is it hard for you to breath when you do physical activity or when lying down? yes no
• Do you have a chronic pulmonary condition (ephysema, bronchitis or ashma? yes no
• Do you have cough, expectoration or chest pain? yes no
• Have you recently experienced any changes in your symptoms or run a fever? yes no
• Do you use Ventolin or other sprays? yes no
• When did you last have your condition checked? yes no
_______________________________________________
• Do you smoke? yes no
• ¿Do you suffer from any cardiac condition/palpitations, arrhythmia, heart rumors, angina pectoris, myocardial infarction, damaged valve, cardiac insufficiency, nyocardiopathy, or high or low blood pressure? yes no
• When did you last have your condition checked? yes no
• How many pillows do you use to sleep?
0-1 more than 1
  
• Do you have a pacemaker? yes no
• Do you have bad circulation, arterial disease or varicose veins in the legs? yes no
• Do you get swollen ankles? yes no
• Do you do any physical exercise (football, tennis, gym, swimming, golf or others? yes no
•Are you capable of running a short distance, go up stairs (more than a flight of stairs), walk fast ona flat terrain, mop floors or carry supermarket bags? yes no
• Do you get shortness of breath when you walk uphill or when you walk fast on a flat terrain? yes no
• Do you faint easily? yes no
• Have you been in a comma due to an accident or disease? yes no
• Do you have any neurological, brain, spinal cordi or nerve condition? yes no
• Have you had seizures or epilepsy? yes no
• Do you suffer from headches? yes no
• Are you taning any medication? yes no
• Have you experience any memory loss? yes no
• Do you have any psychiatric condition (depression, anxiety, etc.)? yes no
•• Do you drink wine, beer, or other alcoholic beverages with meals or throughtout the day? yes no
• Do you take any sleeping pills, any other non-prescribed or prescribed medication by your doctor, or any substance regarded as a drug? yes no
• Is the medication you are taking contraindicated with other medications or foods yes no
• Are you allergic to any medicines, foods, latex, contact allergies (metals, etc.)? yes no
•What are you symptoms? ................................................... ........................................................................................................
• Are you allergic to any anaesthetic or antiinflammatory agents? yes no
• Are you anemic or suffer from any other blood disorder? yes no
• Do you bleed easily when you brush your teeth? Are your menstrual periods abundant? Does it take long for your wounds to stop bleeding? Are you prone to brusing? yes no
• Have you ever developed jaundice (yellowish skin)), hepatits or any other liver problem? yes no
• Have you ever had any problems with your kidneys or urinary tract? yes no
• Do you have arthritis, frequent muscle aches or a rheumatologic disorder? yes no
• Are you a diabetic? Have your blood sugar values gone up during your pregnancies? yes no
• Do you have high cholesterol? yes no
• Do you have or have you had any thyroid disorder? yes no
• Do you suspect you might be pregnant? yes no
•Do you have o have you had reflux, hiatal hernia, heartburn or stomach discomfort due to gastritis or an ulcer? yes no
• Do you have back problems (vertebral colum, cervical area, difficulty to stretch or flex your neck, dorsal cifosis, escoliosis, cyatic, lumbar pain-low back pain? yes no
• Do you have any loose teeth, are lacking any dental pieces, do you wear dentures or implants? yes no
• Do you wear glasses, contact lenses, hearing aids, or intrauterine device (IUD)? yes no
• Do you have glaucoma (high intraocular pressure)? yes no
• Have you had a systematic checkup or corporate medical checkup (paid by your employer) in which the electrocardiogram, chest X-ray, blood tests, or medical examination has yielded abnormal results? yes no
• Do you feel anxious or scared about the procedure under anaesthesia, the surgey, or the actual anaesthesia? yes no
•Is there anything else about your health you think your anaesthesiologist should know about? yes no