Pre-Anaesthetic Questionnaire

Pre-Anaesthetic Questionnaire

Complete the questionnaire and kindly bring the completed form to the hospital on the day of your surgery. This information is vital for developing a safe anaesthetic plan.

If you have seen a specialist (such as cardiologist, pulmonologist, or nephrologist) within the past two years, kindly ensure you obtain any special investigations conducted during your last visit.

Full Names(Required)

Cardiovascular disease

Ischaemic heart disease: angina chest pain, previous cardiac stents or cardiac bypass?
Current or previous diagnosis of heart failure?
Arrhythmias, previous cardiac ablation?
Pacemaker? Make and date of last battery test (bring pacemaker card to hospital).
Can you climb a flight of stairs without stopping due to shortness of breath or angina chest pain?

Chronic Kidney disease

Do you have chronic kidney disease and are you on dialysis?

Airway and respiratory disease

Asthma, emphysema, chronic obstructive pulmonary disease (COPD)
Do you smoke? How many cigarettes per day?
Obstructive sleep apnoea? Do you have a CPAP machine?
Has an anaesthetist ever informed you that you have a challenging airway?
Have you had airway surgery (other than dental work) or head and neck radiotherapy?

Neurocognitive disease

Previous stroke or Transient Ischaemic attack (TIA)?
Dementia or previous diagnosis of cognitive impairment?

Allergies and serious anaesthetic complications

Do you have any allergy to medicine, plaster, latex or food?
Personal or family history of malignant hyperthermia, rhabdomyolysis, muscular dystrophy, sudden death under anaesthesia?
Do you have porphyria?

Previous Surgeries

Previous surgeries?

Chronic medication