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) First Last ID Number(Required)Medical Aid NameMedical Aid NumberHeight (cm)Weight (kg)Cardiovascular disease Ischaemic heart disease: angina chest pain, previous cardiac stents or cardiac bypass? Yes No DetailsCurrent or previous diagnosis of heart failure? Yes No DetailsArrhythmias, previous cardiac ablation? Yes No DetailsPacemaker? Make and date of last battery test (bring pacemaker card to hospital). Yes No DetailsCan you climb a flight of stairs without stopping due to shortness of breath or angina chest pain? Yes No DetailsChronic Kidney disease Do you have chronic kidney disease and are you on dialysis? Yes No DetailsAirway and respiratory disease Asthma, emphysema, chronic obstructive pulmonary disease (COPD) Yes No DetailsDo you smoke? How many cigarettes per day? Yes No DetailsObstructive sleep apnoea? Do you have a CPAP machine? Yes No DetailsHas an anaesthetist ever informed you that you have a challenging airway? Yes No DetailsHave you had airway surgery (other than dental work) or head and neck radiotherapy? Yes No DetailsNeurocognitive disease Previous stroke or Transient Ischaemic attack (TIA)? Yes No DetailsDementia or previous diagnosis of cognitive impairment? Yes No DetailsAllergies and serious anaesthetic complications Do you have any allergy to medicine, plaster, latex or food? Yes No DetailsPersonal or family history of malignant hyperthermia, rhabdomyolysis, muscular dystrophy, sudden death under anaesthesia? Yes No DetailsDo you have porphyria? Yes No DetailsPrevious Surgeries Previous surgeries? Yes No DatesAny complications with previous surgeries?Chronic medication Chronic medication including name, dose, and frequency per day. Please note specific blood thinners.Is there anything else you would like your anaesthetist to know?
