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.