Patient First Name *

Patient Surname *

Contact Phone

Contact Email

Current Medications

Please list details here of all medication you are currently taking. Start each medication on a new line.

Height *

Enter your current height in meters.

Weight *

Enter your weight in kg.

Have you previously had an anaesthetic for surgery? *

Yes

No

Briefly list the surgery you had done

Please detail any problems you had with the anaesthetic (if any)

Has a family member ever had a serious reaction to an anaesthetic? *

Yes

No

Have you ever had an allergic reaction any drugs, or iodine, sticking plasters etc? *

Yes

No

Please state the drug, and reaction

Please tick each of the following you have had and where possible provide details:

Details of medical problems

What is the most active thing you do?

List any sports or other regular exercise

Do you have any specific concerns about your anaesthetic you wish to discuss?

Use this space to add anything else you are concerned about or would like to discuss

Will the anaesthetic fee be covered by: *

ACC

Insurance

Private

Would you like a phone call to discuss the anaesthetic prior to surgery? *

Yes

No

(If you have ticked no the anaesthetist may still contact you to discuss issues relating to the anaesthetic)

Bulent Yaprak Plastic Surgery

M.D, Op.Dr, FEBOPRAS