Questionnaire Preoperative examination Adult

Questionnaire Preoperative examination, Adult

What is your name?

What is the name of your surgeon?

Your birth date:

What kind of operation will be done?

You will soon undergo an operation under general or local anesthesia. To be able to give you a safe anesthesia the anesthesist needs detailed information about your state of health. We therefore ask you to answer the following questions as honestly and completely as possible.

This questionnaire will be sent via an encrypted email. This way we can protect the privacy of sensitive information.

Questionnaire

1. How tall are you (cm) and what is your weight (kg)?

2. Do you have one of the following: dentures, false teeth, jackets, loose teeth, braces or bridges. If yes, what kind?

3. Do you have difficulties with opening your mouth?

Yes

4. Do you smoke? If yes, how many cigarettes per day?

5. Do you drink alcohol? If yes, how much and what kind per day?

6. Do you use drugs? If yes, which ones and how often?

7. Do you use a hearing aid or contact lenses? If yes, which one?

8. Do you have any piercings? If yes, where?

9. Are you on medication? If yes, can you give the name(s) of the medicine, the dose(s) (in mg), and the amount(s) per day?

10. Have you ever been under anesthesia before or did you ever have an operation? If yes, what kind of operation / anesthesia and when?

11. Did you or a member of your family ever have complications during or after an anesthesia? If yes, what kind of problems?

12. Do you have any allergies?

Yes

Are you allergic to Iodine?

Yes

Are you allergic to Plasters?

Yes

Are you allergic to Latex (rubber)

Yes

Are you allergic to Medicines? If yes, which ones?

Are you allergic to Food, if yes what kind?

Other allergies?

13. Have you ever had one of the following diseases or are you still suffering from one of them?

Heart attack (cardiac infarction)? If yes, in what year and who was your treating doctor?

Chest pain? If yes, in what year and who was your treating doctor?

Heart rhythm abnormalities? If yes, in what year and who was your treating doctor?

Heart valve abnormalities? If yes, in what year and who was your treating doctor?

High blood pressure? If yes, in what year and who was your treating doctor?

Low blood pressure? If yes, in what year and who was your treating doctor?

Vascular disease? If yes, in what year and who was your treating doctor?

Asthma? If yes, in what year and who was your treating doctor?

Chronic lung disease? If yes, in what year and who was your treating doctor?

Pneumonia? If yes, in what year and who was your treating doctor?

Emphysema of the lung? If yes, in what year and who was your treating doctor?

Pneumothorax? If yes, in what year and who was your treating doctor?

Tuberculosis? If yes, in what year and who was your treating doctor?

Blood clotting disorder (e.g. easily getting bruises) or other blood disease? If yes, in what year and who was your treating doctor?

Sickle cell disease? If yes, in what year and who was your treating doctor?

Sleep Apnea? If yes, in what year and who was your treating doctor?

Others? If yes, in what year and who was your treating doctor?

14. Are you being treated for diseases of the following organs:

Stomach or oesophagus (e.g. acidity of stomach, reflux)?

Yes

Intestines/abdomen?

Yes

Diabetes?

Yes

Thyroid glands?

Yes

Kidneys?

Yes

Joints (e.g. rheumatism, arthritis)?

Yes

Muscles (dystrophy, myasthenia gravis)?

Yes

Spinal column (e.g. cervical or lumbar spine pain, hernia)?

Yes

Brain (epilepsy/seizures, stroke, TIA, Parkinson's disease)?

Yes

Nervous system (e.g. MS)?

Yes

15. Do you have any other diseases that are not mentioned above? If yes, which ones?

16. Have you recently (the last 8 weeks) been hospitalized in a foreign country? If yes, for what reason?

17. Have you been in contact with a contagious disease (HIV, Hep.B / Hep.C, other)? If yes, which one(s)?

18. Have you ever had a blood transfusion? If yes, did you have any kind of problem / complication during or after blood transfusion? What kind?

Questions only for daycare patients:

19. Will someone be collecting you from the hospital on the day of the operation?

Yes

20. Is there someone at home who can take care of you whitin the first post operative 24 hours?

Yes

Questions only for women:

21. Is it possible that you are pregnant?

Yes

22. Have you been pregnant in the last three months?

Yes

23. Do you suffer from heavy menstruations?

Yes

Declaration of the patient:

24. If necessary, I will agree to a blood transfusion?

Yes

25. If a member of the operating team has an accident with a used needle or instrument, I agree that a blood sample may be taken from me. (Test for: HIV, Hepatitis).

Yes

I would like to have more information about the following topics:

Date of filling in the questionnaire:

Telephone number where we can get in touch with you (day, evening, mobile 06-)

Name and telephone number of person to contact if necessary:

I have read and understood all questions completely and have answered the questions truthfully.

Yes

Bekijk de website via een andere browser dan Internet Explorer voor een betere weergave.