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HEALTH QUESTIONNAIRE
Aesthetic surgery (general anesthesia)
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HEALTH QUESTIONNAIRE (general anesthesia)
1. PATIENT DETAILS*
*mandatory data
2. QUESTIONNAIRE
The information you provide is confidential and essential to ensure your safety. Please answer the following questions carefully and honestly. If you have difficulties answering any of the questions below please leave it blank and ask the physician for help. The information is collected to help us to choose the right treatment and type of anesthesia for your surgery.
3. GENERAL QUESTIONS
Are you generally in good health?
Yes
No
Have you been treated in a hospital in the last two years?
Yes
No
Are you chronically ill?
Yes
No
Do you take any medications on a permanent basis?
Yes
No
Have you taken any medications in the last 6 months?
Yes
No
Are you allergic to anything?
Yes
No
Do you smoke?
Yes
No
Do you take any supplements, herbs etc. (especially St John's wort, nettle, calendula, horsetail)?
Yes
No
Do you drink alcohol?
Yes
No
Do you take any sedatives?
Yes
No
Do you suffer from panic attacks?
Yes
No
4. SPECIFIC QUESTIONS
Do you experience?
a)
breathlessness
Yes
No
b)
swelling
Yes
No
c)
itching
Yes
No
d)
hives
Yes
No
Do you have a tendency to bleed?
Yes
No
Have you ever had an episode of fainting or passing out?
Yes
No
Do you have a pacemaker?
Yes
No
Do you suffer/have you ever suffered from any of the below?
a)
heart conditions
(myocardial infarction, coronary artery disease, other heart deffects, heart arythmia, myocarditis)
Yes
No
b)
other cardiovascular conditions
(hypertension, low blood pressure fainting, shortness of breath)
Yes
No
c)
blood vessel disorders
(varicose veins, phlebitis, poor blood supply to the extremities, intermittent leg pain when walking)
Yes
No
d)
lung diseases
(emphysema, pneumonia, tuberculosis, asthma, chronic bronchitis)
Yes
No
e)
digestive system disorders
(stomach ulcer, duodenal ulcer, intestinal diseases)
Yes
No
f)
liver conditions
(urolithiasis, jaundice, cirrhosis of the liver)
Yes
No
g)
bladder & urinary tract conditions
(inflammation of the kidneys, kidney stones, difficulty urinating)
Yes
No
h)
metabolic disorders
(diabetes, gout)
Yes
No
i)
thyroid problems
(hyperfunction, hypothyroidism, neutral goiter)
Yes
No
j)
nervous system diseases
(epilepsy, paresis, loss of consciousness, paralysis, sensory disturbances, myasthenia gravis)
Yes
No
k)
osteoarticular system disorders
(root pains, degenerative arthritis/joint disease)
Yes
No
l)
blood and coagulation disorders
(hemophilia, anemia, tendency to bleed, nosebleeds, prolonged bleeding after tooth extraction)
Yes
No
m)
eye conditions
(glaucoma)
Yes
No
n)
mood changes
(depression, neurosis)
Yes
No
o)
infectious diseases
- Hepatitis A
Yes
No
- Hepatitis B
Yes
No
- Hepatitis C
Yes
No
- AIDS
Yes
No
- Tuberculosis
Yes
No
- Venereal diseases
Yes
No
- HIV
Yes
No
p)
rheumatic diseases
Yes
No
r)
osteoporosis
Yes
No
s)
other conditions/ailments
Yes
No
Have you ever had an operation?
Yes
No
Have you ever been hospitalised (excluding operations in point 6 above)?
Yes
No
Do you react well to anesthesia?
Yes
No
Have you ever had a blood transfusion?
Yes
No
5. ADDITIONAL QUESTIONS FOR WOMEN
I agree to the processing of my personal data for the purpose of registering for an online medical consultation, in accordance with the
Privacy Policy
.
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