Please list details here of all medication you are currently taking. Start each medication on a new line.
Have you previously had an anaesthetic for surgery?
Has a family member ever had a serious reaction to an anaesthetic?
Have you ever had an allergic reaction any drugs, or iodine, sticking plasters etc?
Please tick each of the following you have had and where possible provide details:
List any sports or other regular exercise
Use this space to add anything else you are concerned about or would like to discuss
Will the anaesthetic fee be covered by:
Would you like a phone call to discuss the anaesthetic prior to surgery?
(If you have ticked no the anaesthetist may still contact you to discuss issues relating to the anaesthetic)