A Z J A N P O RTA E L S

ALGEMEENZIEKENHUISVILVOORDE

P R E S U R G E RY Q U E S T I O N N A I R E

Dear Sir, Madam,

Your state of health could be of importance for the surgery or examination you need to have. May we therefore ask you
kindly to answer the questions below to the best of your ability so that we can learn more about your state of health. It is
advisable to enlist the help of your general practitioner to fill out this list. Please do not forget to sign. We thank you in
advance.

NAME, FIRST NAME Fannon, Adele Marie BLOOD TYPE ?

6 Alvingham Close, Northwich, 90kg

ADDRESS WEIGHT
Cheshire, CW9 5QP England 164cm
HEIGHT
Employment Adviser 15.02.1967
PROFESSION DATE OF BIRTH

What kind of surgery or examination are you being admitted for ?

Gastric Band

What kind of surgery did you have in the past ? Please specify for every surgery the year, the kind of anaesthesia and the
complications if any.

Endometrial Ablation Laser Nov 2006 General Anaesthesia No Complications

Shoulder operation Oct 1993 General Anaesthesia No Complications

Did anyone in your family ever had a problem during general anaesthesia ? If so, what was the problem ?
No

What medication are you using ? Try to specify the dosage and time of intake if possible.
Bendroflumethiazide 2.5mg Morning 08 12 14 16 20 08 12 14 16 20
ISTIN 10mg Morning 08 12 14 16 20 08 12 14 16 20
Cipramil 20mg Morning
08 12 14 16 20 08 12 14 16 20

08 12 14 16 20 08 12 14 16 20

08 12 14 16 20 08 12 14 16 20
08 12 14 16 20 08 12 14 16 20

ANAESTHESIOLOGY PRESURGERY QUESTIONNAIRE

Do you or did you ever suffer from one of the following conditions ?

yes / no yes / no
☐ n
☐ ☐ n
☐
Diabetes Epilepsy
y
☐ ☐ Muscle disease ( myopathie ) ☐ n
☐
Hypertension

Low blood pressure ☐ ☐

n Myasthenia Gravis ☐ n
☐

☐ n
☐ ☐ n
☐
Heart attack ( myocardial infarction ), heart failure Depression, insomnia

☐ n Obstructive sleep apnea ( OSA )

☐ ☐ n
☐
Arrythmia, heart murmur, rheumatic fever

☐ n Parkinson’s disease
☐ ☐ n
☐
Pneumonia

☐ ☐
n Alzheimer’s disease ☐ n
☐
Chronic bronchitis, asthma

☐ n
☐ ☐ n
☐
Pulmonary embolism Hemophilia, porfyria

☐ n
☐ ☐ n
☐
Liver disease, hepatitis A, B, C Leukaemia

☐ n Rheumatism, auto-immune disease

☐ ☐ n
☐
Liver cirrhosis, jaundice

☐ n Kidney disease
☐ ☐ n
☐
Thyroid gland disorder

Eye diseases ☐ n TIA ( transient ischaemic attack ), stroke

☐ ☐ n
☐

☐ n
☐ ☐ n
☐
Phlebitis Multiple Sclerosis

☐ n
☐ ☐ n
☐
Stomach ulcers Blood clotting disorders

☐ n
☐ ☐ n
☐
Gastric hernia, bowel disease AIDS

☐ ☐
n Eczema, hay fever ☐ n
☐
Enlarged prostate gland

☐ ☐ ☐ ☐

☐ n
☐ ☐ ☐
Shortness of breath when climbing stairs

☐ n
☐ ☐ ☐
Shortness of breath when sitting down resting

☐ n Recent and fast decrease in weight

☐ ☐ n
☐
Sleep upright or on many pillows

☐ n
☐ ☐ n
☐
Chest pain during exercise ( angina ) Recent and fast increase in weight

Please elaborate if you answered yes to any of the above.

High Blood Pressure since 1991 Controlled

ANAESTHESIOLOGY PRESURGERY QUESTIONNAIRE

Are you allergic to any of the following products ?
yes / no yes / no
Antibiotics, penicillin ☐ n Tomato, potatoes, chestnuts
☐ ☐ n
☐

☐ n
☐ ☐ n
☐
Sulphonamides Crustaceans, oysters, fish

☐ n
☐ ☐ n
☐
Aspirin Plants like Ficus benjamina or Hevea brasiliensis

☐ n
☐ y
☐ ☐
Paracetamol Mites, pollen

☐ n
☐ y
☐ ☐
Tramadol, Zamadol, Tramake, Zydol, Dromadol Dog or cat hair

☐ n
☐ ☐ n
☐
Local anaesthetics Bandages

☐ n Metals
☐ ☐ n
☐
Other drugs used in anaesthesia

☐ n
☐ ☐ n
☐
Rubber, latex ( gloves, balloons or elastic bands) Jodium

☐ n Others ?
☐ ☐ n
☐
Fruits ( banana, pineapple, kiwi or others )

If you’ve answered yes to any of the above, could you please describe the allergic reaction ? ( difficulty breathing, asth-
ma, runny nose, hives, itching, swelling, rash, shock,..........)

Runny nose

Do you use any of the following products ?

yes / no yes / no
Alcohol ( wine, beer, spirits ) y
☐ ☐ Ticlid, Plavix ☐ n
☐

☐ n
☐ ☐ n
☐
Amphetamins, XTC, cannabis Asaflow

☐ n
☐ ☐ n
☐
Heroin, cocain, ketamin, morphin Paracetamol

☐ n
☐ ☐ n
☐
Nicotin ( cigarettes, cigares ) Aspirin

☐ n
☐ ☐ n
☐
special diet ? Heparin, Fraxiparin, Clexane

☐ n
☐ ☐ n
☐
Homeopathic drugs, medicinal herbs Anticoagulants : Coumadin, Marevan

☐ n
☐ ☐ n
☐
Appetite-repressants Glucophage, Glyciphage, Metomin, Metformin

Please specify your use or consumption.

18-22 Units

FOR WOMEN
yes / no
Are you using the contraceptive pill ? ☐ n
☐

☐ n
☐
Is it possible that you are pregnant now ?

☐ n
☐
Is your period unusually heavy and/or long ?

☐ n
☐
Did you have problems during pregnancy and/or delivery ?

☐ ☐

ANAESTHESIOLOGY PRESURGERY QUESTIONNAIRE

PATIENT INFORMATION

If you are taking aspirin, aspirin-containing products, aspirin-like products or if you are on anticoagulants such as Coumadin or Ma-
revan PLEASE INFORM YOUR PHYSICIAN.

Aspirin and similar drugs interfere with blood clotting and may lead to excessive bleeding during and after surgery. Aspirin should be
discontinued 5 days before surgery, Plavix and Ticlid 10 days, Coumadin and Marevan 3 weeks !

If you are a diabetic patient taking insulin or an oral hypoglycemic agent, do not take your insulin or oral hypoglycemic medication
the morning of surgery. Glucophage, Metomin and Metformin should be discontinued at least 24 hours before surgery.

Before surgery
• DO NOT EAT OR DRINK AFTER MIDNIGHT. This is important because your stomach must be empty when you receive anaes-
thesia. Eating or drinking before your surgery can cause a delay or cancellation of your surgery.

• Smoking : You are advised to stop smoking 24 hours before your surgery. While this can be difficult, it will help improve your bre-
athing and circulation. It also will help decrease breathing problems after your surgery.

• On the morning of your surgery, you should bathe and brush your teeth, but do not swallow any water. Do not use any lotion, cre-
am, powder, or deodorant on your body. Your nurse will help you get ready. You will put on a hospital gown only. You will need to
remove dentures, contact lenses, nail polish, makeup, tampons, hairpieces, jewelry, and any artificial limbs. Valuables must be given
to a family member or friend or locked in the hospital safe. You should empty your bladder right before leaving for surgery.

Medication
• If you are an outpatient or an ambulatory or same-day surgery patient, do not take your daily medications before surgery unless you
are specifically instructed to do so. Medication for cardiac and pulmonary disease or epilepsy should be continued the morning of
surgery.

Operating room
• You will arrive in a holding area in the operating room. An intravenous (IV) needle may be placed in your vein so you can receive
fluids during the surgery. When you are wheeled into the operating room, you will be helped onto the operating room table. Your
blood pressure will be taken, and you may have an oxygen mask placed over your face. Many people will be around you preparing
you for the surgery. If you are receiving a general anesthetic, it will make you fall asleep so that you will not feel any pain or be
aware of anything during the surgery.

Recovery period
• After your surgery you will be taken to the recovery room. During this time you will awaken from the anaesthesia. The nursing staff
will monitor your blood pressure, pulse, breathing and the area of the surgery until you are awake from the anaesthesia. If you have
received a local anaesthetic only, you may be returned directly to your room. Otherwise, you will be returned to your room on a
patient care unit when the anaesthesiologist says you may leave the recovery room. If you are an outpatient surgery patient, after
your recovery period you will be monitored until your doctor determines that you are ready to go home. At this point, your doctor
and nurse will provide you with discharge instructions. Your family member or friend will then be able to take you home.

Do you wish to add anything that might be important for the anaesthesia or the surgery ?
.................................................................................................................................................................................................................

.................................................................................................................................................................................................................

.................................................................................................................................................................................................................
Adele Marie Fannon
UNDERSIGNED,............................................................................DECLARES TO HAVE CAREFULLY READ AND FILLED
OUT THE ABOVE QUESTIONNAIRE.

16.07.08 Adele Marie Fannon

Date : ........................................................ Signature : ..........................................................

ANAESTHESIOLOGY PRESURGERY QUESTIONNAIRE