PERTH ANAE - Pre-Anaesthetic Questionnaire

HEALTH ISSUES & MEDICATIONS
List any other medical problems not mentioned on the previous page or attach a list:
Please Add / upload any documents required (test results, allergies, medications correspondence):

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FAMILY HISTORY: Is there any family history of adverse reactions to anaesthetic medications?
Regular Medications (Tablets/Puffer/Patches/Injections)*

YesNo

REGULAR MEDICATIONS

ALLERGIES

List any previous operations

	Operation	Date (approx)	Details of any problems with the anaesthetic given or side effect (e.g. nausea)
1.
2.
3.

	YES	NO
High Blood Pressure
Heart Attack/Angina
Heart Arrhythmia/Palpitations
Heart Murmur/Heart Valve Disease
Pacemaker/Defibrillator
Asthma/Chronic Lung Disease
Recent Cough/Fever/Viral Infection
Obstructive Sleep Apnoea
CPAP machine (please bring to hospital)
Diabetes
Taking “flozin” diabetes medicine (needs to be stopped for 3 days prior to procedure)
Taking GLP1 agonist injections, eg ozempic (needs to be stopped 4 weeks prior to procedure)
Acid Reflux/Heartburn/Stomach Ulcer
Stroke
Bleeding Disorder/Clots in the legs
Taking blood thinning medicine other than aspirin
Kidney Disease
Liver Disease
Chronic Pain
Family history of adverse reactions to anaethetics

PRE-ANAESTHETIC QUESTIONNAIRE