Child patient health questionnaire

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Please see the sections 'for parents' and 'for children' on my website for frequently asked questions.

Parents of children > 10 mths will be allowed in theatre whilst the child falls asleep.

Children <50kg will be routinely offered either the Gas (face mask) or IV (needle with numbing cream applied) to go to sleep, whichever is best tolerated.

Anxious children may receive a pre-med to help them relax before they come into theatre, please advise the nurse on arrival if you think they need this. They will contact me.

Intellectually disabled adults/ children > 50kg may be offered Gas to fall asleep if this in in their best interests, this will be discussed on an individual basis.

If your child has severe behavioural or anxiety issues please contact my rooms to advise. I will then be able to discuss a plan with you before hand to make it easier.

Name

Surgeon

Age

Age < 1yr

Age < 3yr

Age 3-6yrs

Age 7-16yrs

>18yrs Intellectually disabled adult

Medical issues

Autism

Anxiety/ ADHD/ Behavioural issues

Asthma/ respiratory conditions (other than related to Adenoids/ Tonsils)

Epilepsy/ Neurological disorder

Heart issues - such as congenital heart disease/ previous surgery

Other:

Ability of your child to cooperate (Age > 3)

Very relaxed and cooperative with doctors/ dentists

A bit shy/ anxious/ quiet when visiting new doctors or dentists

Very shy / anxious and on occasion uncooperative

Other:

Clear selection

Has your child had an anaesthetic before?

Yes

Clear selection

If you answered yes, did they had any issues?

Is there a family history severe reactions to anaesthesia (other than more mild reactions such as nausea/ vomiting)

(>3 yrs only) Do you think they will cooperate with sleeping gas given via a face mask?

Yes

Maybe

Clear selection

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