ANAESTHESIA QUESTIONNAIRE: (TO BE COMPLETED BY THE PATIENT (POSSIBLY TOGETHER WITH THE GP))

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1 Version No. 1.0 Valid from dec 2016 Document number DC 491 Unit Anaesthesia ANAESTHESIA QUESTIONNAIRE: (TO BE COMPLETED BY THE PATIENT (POSSIBLY TOGETHER WITH THE GP)) Together with your treating physician, you have agreed to undergo surgery, a procedure or test involving anaesthesia (sedation, general anaesthesia or local anaesthesia, or a combination thereof). Your treating physician has also discussed the benefits of, drawbacks of and alternatives to the anaesthesia proposed. The questionnaires provided have been drafted to assess your health condition prior to the surgery, procedure or test. They also allow the physician to determine which additional tests are necessary to select the most appropriate anaesthesia based on your health condition. Below you will find two questionnaires: 1. A short questionnaire to verify whether a pre-surgical assessment by the anaesthetist is necessary this questionnaire does t apply to procedures where only sedation is used! 2. A comprehensive questionnaire to assess the medical risk related to the anaesthesia and the surgery. It is important to fill in both questionnaires fully and clearly! (in case of sedation: only fill in the comprehensive questionnaire) You can do this on your own, but please try and consult with your surgeon or GP. I. Pre-operative questionnaire pre-operative assessment by the anaesthetist (N/A for sedation) Below you will find a short questionnaire with a few simple questions about your general health condition, which you should answer truthfully by stating " or "". Are you short of breath when exerting mir effort? Do you have chest pain when exerting yourself? Do you have cardiac arrhythmias a pacemaker stents/bypass of the coronary arteries? Do you have insulin-dependent diabetes? Do you have any other illnesses other than those for which you are w having surgery that severely restrict your daily activities? If you answered '' to one or more questions, the anaesthetist has to see you prior to surgery (i.e. before you go to the operating theatre). There are two possibilities: The nurse that supervises your admission arranges a visit from the anaesthetist or anaesthesia nurse to your room. You see an anaesthetist ahead of the procedure, at the campus where you will be admitted. Deurne campus: 03/ available during office hours by appointment only Antwerp campus:

2 03/ available during office hours by appointment only II. Pre-operative questionnaire assessment of medical risk The following questionnaire assesses the medical risk related to the anaesthesia and the surgery. If you have a consultation with an anaesthetist prior to your surgery, make sure you bring in this completed questionnaire. Surname: First name:. Date of birth:../../.. Age: years Telephone: Contact person:... Telephone:... Surgery:... left right N/A. Surgeon:... Date of surgery:../../.. Time:... Blood type:... Weight:... kg Height:... cm Please bring along your blood type card. A correct response to the questionnaire consists of circling or, ticking the corresponding box and describing the type of illness/procedure/condition on the dotted line. 1. Social status Do you live alone? 2. Diseases of the heart and blood vessels Are you receiving or have you received treatment for heart disease? If so, please state which: heart failure heart attack pacemaker bypass coronary artery stents Mitral stesis or mitral insufficiency aortic stesis or aortic insufficiency Other heart valve disease:... Are you taking medication for your heart? If so, fill in on the medication overview Are you short of breath when resting when exerting mir effort? Do you sometimes have chest pain when resting when exerting mir effort? Do you sometimes suffer from swollen feet or legs? If, when:... Are you receiving or have you received treatment for vascular disease? Do you have varicose veins? Have you ever had phlebitis?

3 Do you have problems with your blood pressure? If so high blood pressure low blood pressure Are you taking medication for your blood pressure? If so, fill in on the medication overview 3. Diseases of the lungs and respiratory system Have you ever had a severe lung disease? If so, please mention which: TB pneumonia other:.. Do you have asthma hay fever chronic bronchitis COPD? If you take medication for the above, please fill in on the medication overview Do you currently have a cold or the flu? 4. Diseases of endocrine system Do you have diabetes? If so, please mention which type: Type 1 (juvenile) diabetes Type 2 (adult-onset) diabetes Do you suffer from a thyroid disease? If so, please mention which: Hypothyroidism hyperthyroidism other: Diseases of the digestive system and liver Have you ever had jaundice or other liver diseases? If so, please mention which: Hepatitis A Hepatitis B Hepatitis C other:.. Are you receiving treatment for stomach disease? If so, please mention which: stomach ulcer stomach acid reflux Do you easily suffer from vomiting nausea motion sickness? 6. Diseases of the kidneys and urinary system Do you suffer from kidney disease? If so, please mention which: renal insufficiency kidney stones kidney infection 7. Diseases of the eye Are you receiving treatment for a disease of the eye? If, which: Disorders of nervous system Are you receiving treatment for a disease of the nervous system? If so, please mention which: epilepsy other:.. Are you receiving treatment for depression anger management issues problems with concentration?

4 Have you ever had a brain haemorrhage or cerebral thrombosis (CVA/stroke)? If so, and you are still have after-effects, please state which: speech disorders paralysis other: Do you suffer from a form of dementia? 9. Locomotor system Have you ever been treated for rheumatism or arthritis? Have you ever been treated for back or neck complaints? If, which:... Do have problems opening your mouth? = you are able to fit 2 fingers (one on top of the other) between your teeth 10. Habits Do you smoke? If, how many cigarettes?... a day Were you previously a smoker, but have w quit? If so, when did you quit?.. years ago Do you consume alcohol? If so, how much? glasses a week Do you use drugs or other stimulants on a regular basis? If so, which ones? how often? Aids - Do you have... Dentures? Artificial teeth/dental prostheses? Loose teeth? Contact lenses? A hearing aid? Artificial nails? Piercings? A pacemaker/icd/stimulator? 12. Hereditary diseases Do you have blood relatives with congenital, hereditary conditions or illnesses? If, which: Infection risk Do you suffer from a communicable disease? If, which: Blood clotting

5 Do you continue to bleed long after a tooth extraction or injury? Are you on blood thinners? If so, state which on the medication overview and discuss with your GP, treating physician or anaesthetist! Have you ever had a blood transfusion? Have you ever had a reaction to a blood transfusion (transfusion reaction)? 15. Allergy Are you allergic to certain substances? If so, please mention which: latex rubber plasters Contrast fluids if, which:... disinfectants if, which:... anaesthesia (dentist) if, which:... medication food products/colouring plants/pollen/trees other

6 16. Surgical history Have you had surgery in the past? If, when and which surgeries: Year:... Surgery:. Year:... Surgery:. Year:... Surgery:. Year:... Surgery:. Did the anaesthesia cause any problems? If so, describe the reaction: For female patients only: Are you pregnant or is there a possibility that you are pregnant? Are you breastfeeding? Do you have any further comments/additions/questions?

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