• NEW PATIENT FORM: ANESTHESIA

  • Hello and welcome to Bermuda Pain Relief Center. We ask that you help us by providing as much information as you can regarding your current condition and ongoing treatment as well as any prior diagnostic tests, treatments and medical records that you may have had. This questionnaire is designed to step you through all areas of your past and present medical care. Please complete as much of this form as you are able to prior to your first visit, so that we can use this information at the time of your first visit to get a complete picture of you and your overall condition. Please do not hesitate to ask any of our staff or physicians for assistance if you have any questions or concerns. We look forward to meeting you.

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  • INFORMATION FOR SURGERY

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  • PREVIOUS/CURRENT MEDICAL HISTORY

  • ANAESTHETIC HISTORY

  • ALLERGY HISTORY

  • SUBSTANCE HISTORY

  • Marijuana, cocaine, natural supplements, herbs etc... can affect your anaesthetic. Please inform the anaesthetist if any has been taken in the last week. 

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  • As I have had a general anaesthetic, I understand that I must not be in charge of any vehicle on the public road for 24 hours after my discharge from the surgical center.

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  • ANESTHESIA CONSENT

  • I * (Full name)acknowledge that my doctor has explained to me that I will have an operation diagnostic or treatment procedure My doctor has explained the risks of the procedure advised me of alternative treatments and told me about the expected outcome I also understand that anesthesia services are needed so that my doctor can perform the operation or procedure It has been explained to me that all forms of anesthesia involve some risks and no guarantees or promises can be made regarding the results of my procedure or treatment Although rare unexpected severe complications with anesthesia can occur and include the remote possibility of infection bleeding drug reactions blood clots loss of sensation loss of limb function paralysis stroke brain damage heart attack or death I understand that these risks apply to all forms of anesthesia and that additional or specific risks have been identified below as they may apply to a specific type of anesthesia I understand that the types of anesthesia service checked below will be used for my procedure and that the anesthetic technique to be used is determined by many factors including my physical condition the type of procedure being performed the surgeons preferred anesthesia type as well as my own desire of anesthesia type It has been explained to me that sometimes an anesthesia technique which involves the use of local anesthetics with or without sedation may not succeed completely and therefore another technique may have to be used including general anesthesia

  • STOP HERE!!

    THE REST OF THE FORM IS TO FILLED OUT WITH YOUR ANESTHETIST 

  • TYPE OF ANAESTHESIA

    TO BE COMPLETED BY ANETHETIST

  • Expected Result:  Total unconscious state, possible placement of tube into the windpipe. 

    Technique: Drug injected into the blood stream, breathed into the lungs or by other routes. 

    Risks: Mouth or throat pain, hoarsness, inury to mouth or teeth, awarness under anesthesia, injury to blood vessels, aspiration pheumonia. 

  • Expected Result: Temporary decreased or loss of feeling and/or movement to lower part of body. 

    Technique: Drug injected through needle/catheter placed directly into the spinal canal or immediately outside the spinal canal.

    Risks: Headache , back ache, buzzing in the ears, convulsions, infection, persistent weakness, numbness, residual pain, injury to blood vessels. "total spine"

  • Expected Result: Temporary decreased or loss of feeling and/or movement to a specific limb or area.  

    Technique: Drug injected near nerves providing loss of sensation to teh area of the operation. 

    Risks: Infection, convulsions, weakness, persistent numbness, residual pain, injury to blood vessels. 

  • Expected Result: Temporary decreased or loss of feeling and/or movement to a specific limb.  

    Technique: Drug injected into veins of the arm or leg while using a tourniquet. 

    Risks: Infection , convulsions, persistent numbness, residual pain injury to blood vessels.  

  • Expected Result: Reduced anxiety and pain, partial or total amnesia. 

    Technique: Drug injected into the blood stream, breathed into the lungs or by other routes producing a semi-conscious state.  

    Risks: An unconscious state, depressed breathing, injury to blood vessels.   

  • Expected Result: Measurment of vital signs, availability of anesthesia provider for further intervention. 

    Technique: None

    Risks: Increased awarness, anxiety and/or discomfort.  

  • I understand that the surgeons will be occupied primarily with the surgery and that the administration, maintenance and termination of anesthesia are independent functions and will be supplied by, and the sole responsibility or the anesthetist , Dr. Annie Pinto.  

    I hereby consent to the administration of anesthetics as maybe considered necessary or advisable. I fully understand the above and have had the opportunity to ask questions and received answers to my satisfaction. I understand that a choice of anesthesia providers exists.

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