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.
13. Have you ever had one of the following diseases or are you still suffering from one of them?
14. Are you being treated for diseases of the following organs:
Questions only for daycare patients:
Questions only for women:
Declaration of the patient:
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