Patientenname und adresse:
Vorgesehener Eingriff:
Anasthesie:
Datum:
‘VOM ARZT
AUSZUFOLLEN:
Cambulant O stations
Jahre Gro8e:
Alter:
Geschlecht:
ccm Gewicht: kg
1. Leiden Sie 2urzeit an einer Infektion (2.8. Erkaltung)?
Wenn ja, an welche?
2. Befanden Sie sich in etzter Zeit in arztlicher Behandlung? On Oj
Wenn ja, weswegen?.
nenein j=ja
ono)
3. Haben Sie in den letzten 4 Wochen blutverdtinnende
(gerinnungshemmende) Medikamente (2.8. Asprin®,
ASS, Marcumar®, Heparin, Tyklid®, Pavix®,Iscover®) ein-
genommen?
Wenn ja, welche?
ong]
4, Haben Sie in letzter Zeit andere Medikamente (28. Blu
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