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 Out Patient Clinic Date * Name * Consultant * Address * Height (m or ft) * Weight (kg or stone) BMI * Tel No (Home) 028 Tel No: (Mobile) D.O.B. (DD/MM/YY) * Age * 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 write a list of current medication * Please answer all questions by clicking on the appropriate radio button: Do you have high blood pressure? * Yes No Is your high blood pressure well controlled by medication? Yes No Do you have angina or chest pain? * Yes No Is your angina or chest pain well controlled by medication? Yes No Do you have any other heart problems ie stents in the heart that you take medication for or see your GP/hospital Consultant about? * Yes No Do you have a pacemaker or internal cardiac device? * Yes No Have you ever been told that you have a heart murmur or rheumatic fever? * Yes No Have you ever had a stroke or mini stroke (TIA)? * Yes No When was your most recent stroke? Yes No Have you ever had a blood clot (DVT, PE)? * Yes No Have you had a blood clot within the last six months? Yes No Do you have asthma? * Yes No Is your asthma well controlled by medication? Yes No Do you have COPD/bronchitis or any other chronic lung condition? * Yes No Can you walk up one flight of stairs without getting breathless? * Yes No Do you have sleep apnoea? * Yes No If yes do you use a CPAP machine at night? Yes No Have you had hepatitis, liver disease or jaundice? * Yes No Do you attend a doctor other than a GP for a kidney problem? * Yes No Do you have, or have you had, bleeding problems? * Yes No Are you currently taking any medication for anaemia? Yes No Do you regularly buy medicine for heartburn/indigestion/ulcers? * Yes No Are you prescribed medicine by your Gp for heartburn /indigestion/ulcers? * Yes No Do you have diabetes? * Yes No Do you have thyroid problems? * Yes No Have you ever had convulsions or fits? * Yes No Are you attending a doctor with any other illness? * Yes No Are you taking any prescribed medication to thin your blood? For example Warfarin/ Aspirin/ Clopidrogel/ Plavix/ Dipyridamole/ Persantin/ Plasugrel/ Rivaroxaban/ Dabigatan/ Pradaxa? * Yes No Are you taking any supplements, herbal medicines or vitamins? - Most herbal drugs should be stopped two weeks prior to surgery as they can interfere with the anaesthetic drugs and also affect blood clotting and wound healing. * Yes No Please List your supplements below Have you taken any other prescribed medication within he last six months? Yes No Do you have any allergies (for example drugs, food, latex)? * Yes No Please list and describe any reaction Have you, or any relative had difficulties with anaesthesia? * Yes No Do you attend a doctor with arthritis in your neck or jaw? * Yes No Have you ever suffered from MRSA? * Yes No Have you been an inpatient in hospital within he last three months? * Yes No Are you a health care professional? * Yes No Have you ever suffered from C.Diff? * Yes No Have you ever suffered from any blood borne viruses (HIV, Hepatitis etc)? * Yes No Have you had any previous surgery? * Yes No Please list the surgery you have had starting with the most recent first. Please state year of surgery. Have you had any other surgery/other tests and investigations planned in the future? * Yes No Please list If you smoke, how many cigarettes do you smoke per day? If you do not smoke, then leave the field below empty If you drink how many units of alcohol do you drink a week? (One unit=half a pint of beer, one pub measure of any spirit) (one small 150 ml glass of wine contains 2 units of alcohol). If you do not drink, leave the field below empty. Is there any other information that you feel would be important for us to know? (Leave empty if not) 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. Are you taking HRT? Yes No Are you taking the contraceptive pill? Yes No Could you be pregnant? Yes No 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. Name * Date of Completion * reCAPTCHA