Bulent Yaprak Plastic Surgery
M.D, Op.Dr, FEBOPRAS
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Bulent Yaprak
Surgery Offered
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Clinic Details
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Preoperative Anaesthetic Questionnaire
Preoperative Anaesthetic Questionnaire
Preoperative Anaesthetic Questionnaire
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:
Heart attack
Angina
Undiagnosed chest pain
Heart Failure
Stroke/TIA (mini stroke)
Black outs or faints
Convulsions/fits
Asthma
COPD
Diabetes
Kidney failure
Liver failure
Neurological problems
Issues with bleeding/easy bruising
Hypertension (high blood pressure)
DVT/PE (blood clots in the legs or lungs)
Palpitations associated with chest pain, shortness of breath or dizziness
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)
If you are human, leave this field blank.
Send to Specialist