Your insurance company if you are claiming fees back
Do you wear contact lenses?
Any body piercings?
Any loose teeth, crowns or plates?
Have you ever had an operation? *
If Yes, please list your previous operations and the date if you are able to remember.
Have you ever had sedation before? *
Have you ever had local anaesthetic before? *
Have you ever had a general anaesthetic? (i.e this is where you have been unconscious) *
If yes to any of the above, when was your Anaesthetic and please state if you experienced any problems with any Anaesthetic
Have you or a relative ever had a problem with an anaesthetic?
Do you have any lung problems? (Include chronic diseases and shortness of breath) *
Do you smoke? *
Are you an ex smoker? *
If you smoke we advise that you do not smoke on day of procedure and ideally stop at least weeks before any operative procedure, please note smokers irrespective of number of cigarettes smoked are always at higher risk of general post operative complications compared to non smokers.
Please provide any further information
Have you ever had heart disease or high blood pressure? * Please include investigations such as cardiac catheterisation,
pacemakers and heart operations
I have had swelling of ankles *
Do you suffer from hypertension? *
Do you suffer from angina? *
Have you ever had a heart attack? *
Do you get breathless when walking? *
Do you get breathless lying flat? *
Do you suffer from ankle swelling? *
Do you suffer from any heart arrthymias example Atrial fibrillation AF, heart block, multiple ventricular ectopics etc? *
Do you have a pace maker? *
Have you ever had heart treatment such as defibrillation, coronary angioplasty, coronary stent insertion? *
Do you have any other heart condition not already mentioned above? *
I have had breathlessness on exertion *
Have you ever had kidney, urinary or prostate problems? Women can exclude up to 3 urinary tract infections? *
Do you suffer from renal disease (Chronic kidney failure, infections, renal stones etc)? *
Have you ever had diabetes? * Please include diabetes in pregnancy
Do you have diabetes? *
Do you take tablets for diabetes? *
Do you take insulin for diabetes? *
Have you had bleeding problems or clots? * This includes DVT, pulmonary embolus, Factor V Leiden and Haemophilia
Do you have any condition or problems with easy bleeding &/or bruising (haemophilia, low platelets ITP, bone marrow disorders or drug induced? *
Do you have any condition that makes your blood more ‘sticky’ higher risk or forming clots/ blood emboli e.g factor V Leiden, protein C deficiency, antiphospholipid syndrome APS? *
Have you ever had fits, a stroke, TIA (mini stroke), brain tumor or receive treatment or seen a Neurologist? *
Have you ever had a stroke (CVA) or Transient ishaemic attack (TIA - mini temporary stroke)? *
Do you suffer from fits/epilepsy? *
Do you suffer from neck problems? *
Are you allergic to any drugs, medicines, foods or LATEX Include anything that causes a rash, wheezing, difficulty breathing
or anaphylactic shock? *
Have you experienced any allergy or adverse reaction specifically with Local anaesthetics? *
Have you experienced any allergy or adverse reaction specifically with Sedative drugs? *
Please provide as much information as possible.
If there is anything else that is not covered in the questions above, which you feel we should know, please give further
Are you a healthcare worker and have you had contact with a healthcare setting in the last 4 weeks? Asymptomatic HCW who are pre-op screen negative and not self-isolating due to contact with a suspected/confirmed household contact and are >7 days out from contact with a confirmed/suspected case, can be considered for surgery. *
Have you had a hospital admission (over 24 hours) within the last 4 weeks? *
Are you or a member of your household shielding for 12 weeks as per PHE guidance? *
Do you live in a nursing or residential home? *
The questionnaire will go to our Pre-assessment Consultant Anaesthetic doctor who will coordinate with your consultant anaesthetist.
We will contact you if we need any further information or require any further tests. You are welcome to telephone 0330
2233332 if you have any questions. Thank you for your help and we hope you have a comfortable stay at The Regenerative
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