• PRE-ANAESTHETIC QUESTIONNAIRE

    DR. SILKE BRINKMANN
  • Format: (00) 0000-0000.
  • Gender
  • Date of Birth
     - -
  • Date of Surgery
     - -

  • HEALTH ISSUES

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  • HEALTH ISSUES & MEDICATIONS

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  • Regular Medications (Tablets/Puffer/Patches/Injections)*
  • Rows

  • YOUR ALLERGIES

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

  • PERSONAL DETAILS

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

  • PREVIOUS OPERATIONS / PROCEDURES

  • Rows
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