Dr Aubrey Bristow. PD preoperative questionnaire             anaesthesia@unconsciousness.net    Fax: 020 7935 3466

Please complete this form and bring it with you when you come into hospital.

If you answer YES to any question in BOLD type please send your form to me before admission

Name of patient

Age

Proposed operation

Date of operation

your email address

Please inform me if your child or a relative has had an anaesthetic problem

Have your child ever suffered from any of the following problems:-

Yes

No

mild or controlled asthma

asthma requiring hospital admission or oral steroids

bronchiectasis or cystic fibrosis

other chest problems requiring hospital admission

congenital heart disease

Do any relatives have congenital heart disease

liver disease

kidney failure

kidney problems

allergy to drugs or latex

blood clotting problems or excessive bruising

any blood diseases including lymphoma or leukaemia or anaemia

abnormalities of haemoglobin including sickle cell disease or thalassaemia

diabetes requiring insulin or tablets by mouth

a fit or epilepsy (ignore single fits from high temperatures)

Was the birth uncomplicated and within 4 weeks of the expected date

Please contact me before admission in your child is taking any of the following :-

insulin, digoxin, phentyoin, carbamazepine, steroids, anticoagulants

Your name

Contact telephone number

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