MEDICAL QUESTIONNAIRE

Patient
Name: Surname:
Age: Sex:
Height: cm Weight: kg
Nationality: Country:
Type of procedure: Desired operation date:
Permanent domicile
Municipality: Postal code:
Street: Street number:
E-mail:    
Patient
Fill in or check the appropriate answer
Family history (illness):
All previous surgeries:
Post op complications: NO YES Details:
Previous type of anaesthesia:  general    spinal/epidural      sedation 
Adverse reaction anaesthetics: NO YES Details:
Shortness of breath on exertion: NO YES Details:
Major injuries: NO YES Details:
Spinal disc or cord surgery: NO YES Details:
Allergies: NO YES Details:
Heart attack: NO YES Details:
Chest pain:  NO YES Details:
Heart rhythm disorder: NO YES Details:
Heart murmur: NO YES Details:
High blood pressure: NO YES Details:
Blood transfusion: NO YES Details:
Prolonged bleeding: NO YES Details:
Blood thinning tablets: NO YES What kind:
Haematological disease: NO YES Thalassaemia
Respiratory problems: NO YES Asthma COPD Sleeping apnoea
Hepatic disease: NO YES Hepatitis: A B C Other
Diabetes mellitus: NO YES Diet        Pills       Insulin
Stomach ulcer problems: NO YES Details:
Neurological disease: NO YES Myasthenia    Epilepsy
Renal disease: NO YES Details:
Thyreoid gland disorders: NO YES Details:
Varicose veins: NO YES Thrombosis Embolisation
Is it possible you are pregnant? NO YES Number of children:
Skin conditions: Keloid scarring: NO YES
Smoker: NO YES Alcohol consumption: NO YES
Antidepressants: NO YES  Drugs addiction: NO YES 
Are you on pills to lose weight:  NO YES 
Long term medication:
Anything else:

If you are being treated for some chronic diseases (diabetes, cardiac disease, asthma, etc), please bring with you your last medical report to the hospital. Ask your GP for your regular medication list (name of medication, dosage and frequency of medication) and the list of diseases which you have been/are treated for.

I am fully aware that if any answer provided in this questionnaire is not true or complete, the operation can be cancelled with no refunds. The provider accepts no liability for damages occurred as a result of provision of untrue or incomplete information. This questionnaire is only provisional in a character and will be accompanied by a detailed preoperative examination. If this examination reveals any significant problem, the operation is delayed or cancelled, whichever is appropriate.