(07) 3359 7011 (07) 3359 7022 Holy Spirit Northside 627 Rode Road, Chermside Qld 4032

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In order to plan your anaesthetic in advance it is helpful for us to know about your medical history.

Please fill in the pre-op questionnaire and return the form to us.

Date of Birth

Anaesthetists name

Please select your anaesthestists name:

Your past anaesthetic and surgical history

Have you ever had an operation before?

If so please give details:

Have you had any problems with the anaesthetic for the above operations?

If so please provide details:

Your medical history

Do you have any of the following? (please tick)

 Diabetes Sleep Apnea Heart attack History of organ transplant Stroke (CVA, TIA)
 DVT or PE (blood clots) Asthma Pacemaker History of chemotherapy High blood pressure

Do you have any allergies? (please specify)

Your medications

Are you on any drugs that may have effect on blood thinning?

If so, which of the ‘blood thinners‘ or anti-coagulants are you on?

Please list your regular medication including strength and how often you take them:

Are there any other relevant details or requests you wish to add?