Primary Questionnaire for Surgery / Anaesthesia

Please either print off the PDF and post it to us or fill in the form below.

Primary Questionnaire for Surgery / Anaesthesia
It is important that you complete this questionnaire as accurately as possible.
This information will be used to plan for your date for surgery.
Please answer all questions by clicking on the appropriate radio button:

Women Only

Please answer all questions by clicking on the appropriate radio button. If you are a male, then please just skip the next 3 questions.

Planning your discharge from hospital

After your procedure you will need to be accompanied home by a responsible adult and have someone to stay with you for the first 24 hours after any general anaesthetic.

If you feel you need assistance with this you must contact your GP to make the necessary arrangements.


The information given above is correct to the best of my knowledge at the time of completion.

Sending