Before anastheysia questtionaire

Name: Surname:

Sex: Age: Occupation: job (toxic)

Phone number :

Have or have had one of these disorders?

1. Heart problems: the effort pain, palpitations, edema, heart pocket, etc..
2. Hypertension / hypotension: what values?
3. A pulmonary disease: efizem, tuberculosis, asthma, chronic bronchitis, bronsiectazie, etc..
4. Thrombophlebitis , varices
5. Acute/ chronic hepatitis, cirrhosis, jaundice
6. Diabetes mellitus, Bazedow disease, hypothyroidism, adrenal insufficiency, other endocrine
diseases
7. Glaucoma and other eye conditions
8. meningitis, encephalitis, seizures, peripherals, etc..
9. A kidney disease: glomerulonephritis , renal failure, etc..
10. Myasthenia,
11. are you allergic to medicines or food?
12. Other diseases: chronic diseases: are you pregnant or are you at your monthly menstruation?
13. DO you bleed more than 10 minutes after an injury?

A: Have you ever received a blood transfusion? What reactions have occurred!

B: Do you take medicines frequently? Which one and in what doses?

C: Do you smoke ? How many cigarettes you smoke per day?

D: DO you Drink? Occasionally (O), frequently (F), no (D)

F When did you eat last?

The nature and operation objectives and risks of anesthesia and surgery were explained to me.

I am fully aware (of) the type of surgery, risks, possible intraoperative complications - surgical and
anesthesiology.

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