Dr Aubrey Bristow. 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 as soon as possible

Name                                                                                                       Date of Birth

Your email address                                                                              Tel:

Proposed operation                                                                              Date of operation

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

Have you ever suffered from any of the following problems:-

Yes

No

mild or controlled asthma

asthma requiring hospital admission or oral steroids

shortness of breath on exercise or climbing stairs

chronic bronchitis or emphysema or bronchiectasis

sleep apnoea or significant snoring

chest pain or angina or a heart attack

Do you have a pacemaker

a heart murmur

heart operations, angioplasty, stents or other heart disease

liver disease

pancreatitis

Indigestion

kidney failure

kidney problems

other urinary problems including prostate disease

allergy to drugs or latex

rheumatoid arthritis or stiff neck or osteoarthritis

any trauma involving the neck or the chest

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

any psychiatric disease other than mild depression

Please contact me before admission in you are taking any of the following :- heparin, warfarin or clopidogrel,

monoamine oxidase inhibitors, insulin, digoxin, phentyoin, carbamazepine, thyroxine, steroids, or chinese herbs

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