Preoperative Anaesthetic Questionnaire

Preoperative Anaesthetic Questionnaire
Please list details here of all medication you are currently taking. Start each medication on a new line.
Enter your current height in meters.
Enter your weight in kg.
Have you previously had an anaesthetic for surgery? *
Has a family member ever had a serious reaction to an anaesthetic? *
Have you ever had an allergic reaction any drugs, or iodine, sticking plasters etc? *
Please tick each of the following you have had and where possible provide details:
List any sports or other regular exercise
Use this space to add anything else you are concerned about or would like to discuss
Will the anaesthetic fee be covered by: *
Would you like a phone call to discuss the anaesthetic prior to surgery? *
(If you have ticked no the anaesthetist may still contact you to discuss issues relating to the anaesthetic)