Pre-Anaesthetic Questionnaire
Please fill out the pre-anaesthetic questionnaire below and click submit to send back to us. Fields marked with * must be filled in.
Name
*
First Name
Last Name
Phone Number
Email
Date of Birth
*
/
Day
/
Month
Year
Date
Weight
*
KG
Height
*
CM
Anaesthetist
*
Please Select
Dr Gianpiero Traini
Date of Operation
*
/
Day
/
Month
Year
Date
Hospital
*
Have you had general anaesthesia before?
*
Yes
No
Do you have medical problems in the following areas?
Heart
Respiratory
Kidney
Please specify if you have any other medical problems.
Details if any.
Please provide details of any regular medications (including herbal medicines).
Details if any.
Please provide details of any allergies.
Details if any.
Do you have reflux (GORD)?
*
Yes
No
Do you have obstructive sleep apnoea?
*
Yes
No
Do you smoke?
*
Yes
No
Do you drink alcohol - more than 2 drinks each day for more than 5 days a week?
*
Yes
No
Please verify that you are human
*
Submit
Should be Empty: