HEALTH QUESTIONNAIRE

Aesthetic surgery (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?
    YesNo
    Have you been treated in a hospital in the last two years?
    YesNo
    Are you chronically ill?
    YesNo
    Do you take any medications on a permanent basis?
    YesNo
    Have you taken any medications in the last 6 months?
    YesNo
    Are you allergic to anything?
    YesNo
    Do you smoke?
    YesNo
    Do you take any supplements, herbs etc. (especially St John's wort, nettle, calendula, horsetail)?
    YesNo
    Do you drink alcohol?
    YesNo
    Do you take any sedatives?
    YesNo
    Do you suffer from panic attacks?
    YesNo
    4. SPECIFIC QUESTIONS
    Do you experience?

    a) breathlessness
    YesNo
    b) swelling
    YesNo
    c) itching
    YesNo
    d) hives
    YesNo
    Do you have a tendency to bleed?
    YesNo
    Have you ever had an episode of fainting or passing out?
    YesNo
    Do you have a pacemaker?
    YesNo
    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)
    YesNo
    b) other cardiovascular conditions (hypertension, low blood pressure fainting, shortness of breath)
    YesNo
    c) blood vessel disorders (varicose veins, phlebitis, poor blood supply to the extremities, intermittent leg pain when walking)
    YesNo
    d) lung diseases (emphysema, pneumonia, tuberculosis, asthma, chronic bronchitis)
    YesNo
    e) digestive system disorders (stomach ulcer, duodenal ulcer, intestinal diseases)
    YesNo
    f) liver conditions (urolithiasis, jaundice, cirrhosis of the liver)
    YesNo
    g) bladder & urinary tract conditions (inflammation of the kidneys, kidney stones, difficulty urinating)
    YesNo
    h) metabolic disorders (diabetes, gout)
    YesNo
    i) thyroid problems (hyperfunction, hypothyroidism, neutral goiter)
    YesNo
    j) nervous system diseases (epilepsy, paresis, loss of consciousness, paralysis, sensory disturbances, myasthenia gravis)
    YesNo
    k) osteoarticular system disorders (root pains, degenerative arthritis/joint disease)
    YesNo
    l) blood and coagulation disorders (hemophilia, anemia, tendency to bleed, nosebleeds, prolonged bleeding after tooth extraction)
    YesNo
    m) eye conditions (glaucoma)
    YesNo
    n) mood changes (depression, neurosis)
    YesNo
    o) infectious diseases
    - Hepatitis A
    YesNo
    - Hepatitis B
    YesNo
    - Hepatitis C
    YesNo
    - AIDS
    YesNo
    - Tuberculosis
    YesNo
    - Venereal diseases
    YesNo
    - HIV
    YesNo
    p) rheumatic diseases
    YesNo
    r) osteoporosis
    YesNo
    s) other conditions/ailments
    YesNo
    Have you ever had an operation?
    YesNo
    Have you ever been hospitalised (excluding operations in point 6 above)?
    YesNo
    Do you react well to anesthesia?
    YesNo
    Have you ever had a blood transfusion?
    YesNo
    5. ADDITIONAL QUESTIONS FOR WOMEN
    wsparcie
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      Przepraszamy, obecnie jesteśmy niedostępni. Zostaw wiadomość, odpowiemy najszybciej jak to możliwe.
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