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
Please list details here of all medication you are currently taking. Start each medication on a new line.
Enter your current height in meters.
Enter your weight in kg.
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)

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

Anaesthetic form