PRE-OPERATIVE ASSESSMENT PLEASE COMPLETE THIS FORM AND BRING TO by hjkuiw354

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									         PRE-OPERATIVE ASSESSMENT                               PLEASE COMPLETE THIS FORM
                                                                AND BRING TO THE HOSPITAL




Directions to Patients:
1.      Please complete this form for your Anaesthetist, they will review it with you prior to your surgery.
2.      Proper completion of this form is important and will help to minimize the risks associated with anesthesia.
3.      This form must accompany you to the hospital. Please do not mail or hand it over to nursing staff.
4.      Your Anaesthetist will meet you pre-operatively and answer all your questions.
1.       Proposed surgery
                                                                 6.      Hours since last food or drink intake
                                                                 7.      What medications do you take at home?
2.       Recent hospitalizations/surgery (within two
                                                                         (Please list name and dose of each):
         years) / surgery




3.       Significant medical problems (check the
         conditions that apply):
         ____ High blood pressure
         ____ Chest pain, angina, any cardiac
                problems
         ____ Other heart conditions
         ____ Hepatitis/liver trouble
                                                                 8.      Please list any drug allergies.
         ____ Ulcers, previous and surgery, any GI
                                                                         Drug
                problems, gastric reflux
                                                                         Describe type of drug reaction
         ____ Asthma, shortness of breath,
                emphysema
         ____ Kidney problems                                    9.      Previous anesthetics - have you had any
         ____ Diabetes or endocrine problems                             unusual reaction to anesthetics?
         ____ Bleeding tendency                                          ____ Yes ____ No
         ____ Nervous disorders, strokes, seizures, etc.                 Please describe
         ____ Skeletal or muscle problems
                Other                                                    Have any relatives had unusual reactions to
                                                                         anesthetics?
4.       Describe your use of:
                                                                         ____ Yes ____ No
         Tobacco
                                                                         Please describe
         Alcohol
         Non-prescription/social drugs
                                                                 10.     Do you have any dental implants, crowns,
                                                                         bridges, etc., loose or damaged teeth?
5.       Are you currently (please check):
         ____ Pregnant
         ____ Suffering from: a cold, sore throat, any           11.     For further information call 07 3284 1892
               infection


Patient Signature                                                                     Date




Version: August 2010

								
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