• PRE-ANAESTHETIC QUESTIONNAIRE

    DR. SILKE BRINKMANN
  • Format: (00) 0000-0000.
  • Gender
  • Date of Birth
     - -
    2 digit day, 2 digit month, 4 digit year
  • Date of Surgery
     - -
    2 digit day, 2 digit month, 4 digit year

  • HEALTH ISSUES

  • MEDICAL PROBLEMS
    Rows

  • HEALTH ISSUES & MEDICATIONS

  • Browse Files
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  • Regular Medications (Tablets/Puffer/Patches/Injections)*
  • REGULAR MEDICATIONS
    Rows

  • YOUR ALLERGIES

  • Allergies (to medications/tapes etc)*
  • ALLERGIES
    Rows

  • PERSONAL DETAILS

  • EXERCISE: Can you climb two flights of stairs?*
  • False Teeth
  • SMOKING: Do you smoke?*

  • PREVIOUS OPERATIONS / PROCEDURES

  • List any previous operations
    Rows
  • Should be Empty: