Azienda Provinciale per i Servizi Sanitari
Provincia Autonoma di Trento
Distretto Giudicarie e Rendena
Via Ospedale, 8 - 38079 Tione (TN)
OPERATIVE UNIT OF ANAESTHESIA AND INTENSIVE CARE
Tel. 0465/331384 – fax 0465/331254
Director: Dr. Fabio Ianeselli
ANAESTHESIOLOGICAL ASSESSMENT AND INFORMED
CONSENT FORM FOR PATIENTS UNDERGOING SURGERY
Dear Sir, Dear Madam,
with reference to the surgery operation you will undergo, there is the need to gather information
useful for you and for the anaesthetists working in this hospital.
This form is divided into three parts; one for the gathering of information about the patient’s
health conditions and about previous surgery operations, if any; the second part refers to the
patient’s informed consent, as envisaged by the Società Italiana di Anestesia, Analgesia,
Rianimazione e Terapia Intensiva (S.I.A.A.R.T.I. 1992) (Italian Anaesthesia, Analgesia and
Intensive Care Society); the third part contains general recommendations for the patient.
I kindly invite you, in your interest and in the interest of the physician who shall administer
anaesthesia, to carefully read this form, to fill it in and hand it over to the anaesthetist who will visit
you before surgery.
Thank you for your collaboration.
Are you currently under treatment by your
1) family doctor? 11) Do you have varicose veins? ____________________
If yes, why?_________________
12) Do you have respiratory problems (frequent cough,
periodical bronchitis, emphysema, asthma…?)
2) Do you suffer from allergies, to what? ______________________________________
13) Have you ever suffered from these diseases?
3) Do you regularly take drugs? _________ a) renal colic □ renal calculus □
ones?______________________________ renal infections □ other □
b) liver colic □ liver calculus □
hepatitis (jaundice) □ other □
Have you ever undergone
If yes, what kind of
surgery?_________________ c) ictus □ paralysis □ Parkinson □
___________________________________ Muscle diseases □ other □
d) ulcer □ gastritis □
5) Did you tolerate the anaesthesia well?_________ goitre □ thyroid malfunction □
14) Do you have diabetes? Yes □ No □
Are there any cases of “incidents due to
6) anaesthesia” If yes, what kind of drugs do you take?________________
in your family? ___________________ ______________________________________
15) Do you smoke ? □ yes □ no, How many cigarettes?________
If you quit, when? ______________
7) Have you ever had blood transfusions? ______________________________________
16) Do you drink alcoholic drinks? □yes □no
Are you informed about the surgery
8) operation you will More than 1l. wine a day □yes □no
___________________________________ More than 3 beers a day □yes □no
Strong drinks □yes □no
Have you heart problems (breathlessness,
when you go up the stairs, dyspnoea,
chest pain)? Your height is of cm ________________
___________________________________ Your normal weight is kg _______________
Have you taken on weight recently?_______________
10) Your blood pressure is:
normal □ - high □ - low □ Have you lost weight recently? ________________
INFORMED CONSENT TO ANAESTHESIA
(S.I.A.A.R.T.I Recommendations 1992)
Anaesthesiological assessment of surgery risks for the operation of
1. HEALTHY PATIENT
2. PATIENT SUFFERING FROM A MILD SYSTEMIC DISEASE
3. PATIENT SUFFERING FROM A SEVERE SYSTEMIC DISEASE THAT
HAMPERS HIS/HER ACTIVITY ALTHOUGH NOT INCAPACITATING
4. PATIENT SUFFERING FROM A SEVERE SYSTEMIC INCAPACITATING DISEASE,
THAT IS A CONSTANT THREAT TO LIFE
5. PATIENT IN VERY SERIOUS CONDITIONS,
NOT EXPECTED TO LIVE 24 HOURS IRRESPECTIVE OF OPERATION
MILD MODERATE MODERATE-HIGH VERY HIGH
I, the undersigned________________________________________, in view of the scheduled
surgery intervention declare to have obtained exhaustive information about the kind of anaesthesia I
will undergo and about the monitoring techniques of vital functions.
I likewise declare to be aware that my general conditions put me at risk for the following
I agree that the anaesthetist changes the technique agreed upon if circumstances require it.
I also declare of having authorised transfusions with homologous blood and/or blood derivatives
and to be aware of risks connected to transfusions.
Upon careful consideration of the situation, I accept all necessary procedures and confirm that I had
exhaustive answers to my questions.
Remarks : _________________________________________________________________________________
Signature of the patient ________________________________________
Signature of the guardian ________________________________________
Signature of the anaesthetist ____________________________________________
There are a few rules that should be observed before undergoing anaesthesia, both
local or general.
1. Drugs regularly taken by the patient shall be communicated to the unit medical staff or to
the anaesthetist. These shall inform the patient whether he/she can continue to take them or
shall suspend them and how much before the operation.
2. Do not eat after midnight of the day preceding surgery.
3. Smoking is strictly forbidden on the day of surgery.
4. Before surgery make sure not to wear: dental prostheses, contact lenses, rings, earrings and
piercing, glasses and watches which shall be given to a trustworthy person.
5. Before surgery remove lipstick, make-up, mascara and nail polish.
6. Relatives shall not crowd the patient’s room on the day of surgery. The unit staff shall
inform about who can or must stay for assistance, if necessary.