Preop Eng – Service d'anesthésie

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Preoperative questionnaire

1 Personal informations

2 Allergies

3 Lungs and heart

4 Coagulation and médication

5 Operations

Identity
Name First name
Date of Birth
dd/mm/yyyy
Email
*@*.*
Height (cm)
Weight (kg)
Age
Date of surgery
Proposed Surgery
Side to operate (if applicable)
- Right
- Left
- Bilateral
Surgeon

Medical background
Have you ever suffered from serious health problems?
- No
- Yes
Can you describe?
Allergy
Do you have any allergies ?
- No
- Yes
What are you allergic to ?
- Latex
- Disinfectant
- Pollen
- Animals
- Bananas or kiwi or tomatoes
- Bandage
- Contrast fluids
- Fish or shellfish
- Dust
- Metals
- Other (ex: medicine)
What happens ?
- red skin or eruption or itch
- runny nose
- face swelling
- asthma
- hypotension or fainting
- vomiting or diarrhoea
- other

Tobacco
Do/did you smoke ?
- No
- Yes
Alcohol
Do you drink alcohol, beer or wine?
- No
- Yes
Drugs
Do you use drugs?
- No
- Yes
How many per day ? / When did you stop?
How much per day?
What drug and when?
Lungs
Do you have ...
- asthma
- chronic bronchitis
- cough
- nocturnal snoring
- shortness of breath at rest or when you get dressed
- shortness of breath with light effort (walking 100 meters)
- shortness of breath with moderate effort (two flights of stairs)
- sleep apnea
Heart
Do/did you have/had ... ?
- palpitations
- chest pain radiating to neck or left arm with effort
- chest pain radiating to neck or left arm at rest
- high blood pressure
- low blood pressure
- other heart problem

Coagulation
Do/did you have/had... ?
- frequent nose bleeding
- frequent haematoma
- bleeding gums
- wounds bleeding more than 5 minutes
- medication affecting coagulation (Asaflow, Plavix, Fraxiparine, Sintrom, Xarelto,...)
- a blood transfusion
Metabolism
Do you have ...
- diabetes ?
- thyroid disease ?
- stomach ulcers ?
- Reflux of acid burn ?
Current pathology
Right now, are you being treated (for a disease or something else) by your doctor / specialist, appart from the planned intervention?
- No
- Yes
Could you describe?
Medications
Name Dosage How many times per day

What medications do you take ? Click on "+" to add

Operations
Have you had surgery before ?
- No
- Yes
Name of the surgery Date (year) Type of anaesthesia
Postoperative
After these operations, you have suffered from
- nausea or vomiting
- bad wake up
- difficulty breathing
- sore throat
- memory loss
- loss of sensibility (arm, leg,...)
- pain during more than 3 months after surgery
- other
Can you explain?
Various
Do you have ...
- an upper removable denture
- a lower removable denture
- a fixed upper denture
- a fixed lower denture
- wobbly or fragile teeth
- hearing aids
- contact lenses
Notes
Do you have any comments to add?