Pre-operative Anaesthetic Questionnaire

The purpose of this questionnaire is to let our anaesthetist know your previous surgical history and health status for up-coming surgery with us.

Please complete it at least a week prior to your surgery with Dr Yaprak.

Preoperative Anaesthetic Questionnaire

Patient First Name *

Patient Surname *

Contact Phone

Contact Email

Current Medications

Please list details here of all medication you are currently taking. Start each medication on a new line.

Height *

Enter your current height in meters.

Weight *

Enter your weight in kg.

Have you previously had an anaesthetic for surgery? *

Yes

Briefly list the surgery you had done

Please detail any problems you had with the anaesthetic (if any)

Has a family member ever had a serious reaction to an anaesthetic? *

Yes

Have you ever had an allergic reaction any drugs, or iodine, sticking plasters etc? *

Yes

Please state the drug, and reaction

Please tick each of the following you have had and where possible provide details:

Heart attack

Angina

Undiagnosed chest pain

Heart Failure

Stroke/TIA (mini stroke)

Black outs or faints

Convulsions/fits

Asthma

COPD

Diabetes

Kidney failure

Liver failure

Neurological problems

Issues with bleeding/easy bruising

Hypertension (high blood pressure)

DVT/PE (blood clots in the legs or lungs)

Palpitations associated with chest pain, shortness of breath or dizziness

Details of medical problems

What is the most active thing you do?

List any sports or other regular exercise

Do you have any specific concerns about your anaesthetic you wish to discuss?

Use this space to add anything else you are concerned about or would like to discuss

Will the anaesthetic fee be covered by: *

ACC

Insurance

Private

Would you like a phone call to discuss the anaesthetic prior to surgery? *

Yes

(If you have ticked no the anaesthetist may still contact you to discuss issues relating to the anaesthetic)

If you are human, leave this field blank.

Thank you! Please note that we are having some temporary issues with this form. Even if it appears to not submit, we probably have your information. One of our friendly team will contact you to confirm.

All our surgeries are performed at Braemar Hospital. For more information about Braemar Hospital, please go to their website. HERE.

If you have any further queries, please contact us

Pre-operative Anaesthetic Questionnaire

The purpose of this questionnaire is to let our anaesthetist know your previous surgical history and health status for up-coming surgery with us.

Please complete it at least a week prior to your surgery with Dr Yaprak.

Surgery Options with Dr Yaprak