Pre-Op Questionnaire - Northside Anaesthesia

It’s time to start counting sheep

Delivering the safest anaesthesia guided by evidence-based medicine.

Pre-Op Questionnaire

Name

Date of Birth

Height

Weight (Kg)

Surgeons Name

Proposed Operation Date

Anaesthetist Name

Previous Surgical procedures and Anaesthetic History

Medical History

List any Prescription or over the counter Medications you are taking including their doses.

Do you have an Allergies?

Any other relevant information you would like to add?