PRE-ANAESTHETIC QUESTIONNAIRE

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by DR MOHAMMED ZAHID YERGATTI (ANAESTHESIOLOGIST AND INTENSIVIST)
This form is a preliminary assessment of your health status for administration of anaesthesia

Email *

This form is being filled by *

Self

By relative or friend

By nurse

By doctor

Full name of person filling the form.

What is patient's full name? *

What is your age? *

What is your gender? *

What is your address? *

What is your weight ( approx) in kg? *

What is your height ( approx) in feet inches? *

What surgery are you posted for? *

Who is the surgeon? *

When is your surgery approximate date? *

Do you have any allergies to medicine or food? If yes then mention the details. *

Are you hard of hearing or use any hearing aids? *

Yes

Do you have vision loss or use glasses? *

Yes

List all the medications which you use regularly. (write none if not using anything) *

Do you smoke? If yes, enumerate how many cigarettes and from how many years? *

Do you consume alcohol? If yes, the enumerate how many glasses and how many years? *

Did you have any surgery before? if yes then write the surgery and approximate year. *

Have you had any complication during surgery? *

Yes

dont know?

What activities can you do without getting breathless or tired? *

eating or working on computer

walking down stairs or walking in your house

walking 1 or 2 blocks on ground level

raking leaves or gardening

climbing stairs of one floor or dancing

playing golf or carrying clubs

playing single tennis

rapidly climbing stairs or slowly jogging

jumping rope and slowly or cycling moderately

swimming quickly , running or jogging briskly

skiing cross country or playing full basketball court

rapidly running for moderate to long distances

Required

Do you snore during sleep? *

Yes

Do you have morning headaches or dizziness? *

Yes

Do you have any loose or chipped teeth? (You can touch your teeth with finger and find out) *

Yes

Do you use dentures? If yes specify removable or fixed ? *

Have you had any stroke , paralysis, seizures,fits, facial waekness or difficulty speaking in your lifetime? *

Yes

Have you had any hearing problem or vision loss or memory loss? *

Yes

Did you have change in voice recently? *

Yes

Do you suffer from asthma or bronchitis or breathing difficulty? *

Yes

Do you use home oxygen, bipap machine at home ? *

Yes

Did you have increased heartbeat palpitations anytime? *

Yes

Did you have any heart murmur anytime? *

Yes

Did you have chest pain and sweating any time? *

yes

Did you have fluid in the lungs anytime? *

yes

Do you have any history of any heart disease? *

Yes

Have you or anyone in your family had heavy bleeding from nose, gums, tooth extraction, thalasemia or prolonged bleeding? *

Yes

Have you ever had problems of blood like anaemia, leukemia, sickle cell disease or blood transfusions? *

Yes

Tick if you had these problems in your lifetime? *

none

liver related (like cirrhosis, hepatitis, jaundice)

kidney (stones, failure, dialysis)

digestive systems ( frequent heartburn, hiatus hernia, stomach ulcer)

back pain continously

jaw pain

thyroid gland problems

glaucoma (increase pessue in eye)

Required

Do you suffer from these? Tick which ever is applicable? *

none

diabetes ( high sugar)

hypertension (high bp)

asthma

tuberculosis (TB)

Required

Have you ever been treated for cancer? *

Yes

For women, when was your last menstrual period? *

For women, do you have regular periods? *

Yes

sometimes regular sometime irregular

having irregular periods now

For women, do you think you are pregnant? *

Yes

List all the diseases which you suffer from not listed above. (write none if no contribution) *

Any comments or suggestions to your nurse or anaesthetist?

Submit

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