Questionnaire Preoperative examination Child

Questionnaire Preoperative examination, Child

What is the name of your child?

What is the name of the surgeon?

Your child's birth date:

What kind of operation will be done?

The purpose of this questionnaire is to get detailed information about the health of your child. We therefore ask you to answer the following questions honestly. Please fill in the complete questionnaire. This will help to keep the preoperative examination short.

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

Questionnaire

1. How tall is your child (cm)?

2. What is the weight of your child (kg)?

3. Does your child have allergies?

Yes

Is your child allergic to Iodine?

Yes

IS your child allergic to Plasters?

Yes

Is your child allergic to Latex (rubber)?

Yes

Is your child allergic to Medicine e.g. antibiotics, if yes, which ones?

Is your child allergic to Food, if yes, what kind of food?

Does your child have any other allergies?

4. Is your child taking medication? If yes, can you give the name(s) of the medicine, the dose(s) (in mg), and the amount(s) per day?

5. Is your child under treatment (or control) by a medical specialist? If yes, can you give the name of the consultant, the type of consultant, the hospital and the reason for treatment?

6. Has your child ever had an operation or anesthesia before? If yes, can you give the kind of operation, the hospital and the year of the operation?

7. Have there been problems or complications associated with the anesthesia or operation? If yes, which ones?

8. Did you or a member of your family ever had problems associated with anesthesia? If yes, what kind?

9. Does your child easily suffer from nausea or vomiting?

Yes

10. Are there any hereditary diseases (such as sickle cell disease, heart diseases, muscle diseases) in your family? If yes, which ones?

11. Does (or did) your child suffer from one of the following diseases?

Congenital disorder?

Yes

Chromosomal disorder (e.g. Down's Syndrome)?

Yes

Congenital heart disease, heart murmur?

Yes

Asthma, bronchitis or other lung disease?

Yes

Blood disease (e.g. sickle cell or hemophilia)

Yes

Disease of the neural system?

Yes

Disease of the kidneys?

Yes

Diabetes?

Yes

Muscle diseases?

Yes

Disease of the vertebra or joints?

Yes

Disease of the brain (e.g. epilepsy)?

Yes

Other diseases?

Yes

If you have marked one of the above mentioned diseases will you be so kind to give as much information as possible and bring a copy of the report of the consultant who is in charge?

12. If your child has a wound, does the bleeding stop within half an hour?

Yes

13. Does your child get bruises easier than other children?

Yes

14. Does your child have problems to move the head and neck?

Yes

15. Can your child open the mouth widely?

Yes

16. Does your child have one of the following: Loose teeth, brackets, abnormalities of the mouth, others?

17. Does your child wear contact lenses?

Yes

18. Did your child suffer from a contagious disease within the last three weeks?

Yes

19. Did your child have contact with a contagious disease within the last three weeks?

Yes

20. Has your child been vaccinated within the last two weeks? If yes, what kind of vaccination and on which date?

21. Will your child be vaccinated soon? If yes, when and what for?

22. Has your child recently been hospitalized in a foreign country? If yes, what for?

The following questions are only for parents of children that are younger than one year:

23. Has your child been born more than two weeks earlier than expected

Yes

24. Has there been any complications after the delivery? If yes, what kind?

25. If necessary, would you give permission for a blood transfusion?

Yes

26. Are there any other important facts that we need to know?

27. Are there any questions? Do you need additional information?

Name of mother/father:

Date of filling in the questionnaire:

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

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.