Completing Your Questionnaire

    We are delighted that you have chosen The Regenerative Clinic for your operation. We would be grateful if you would spend
    a few minutes completing this questionnaire which will be revised by our dedicated Pre-assessment Consultant Anaesthetic
    doctor. They will liaise with you to decide whether any further tests or investigations are needed and to ensure your
    anaesthetic is the safest possible whilst avoiding the risk of cancelling your operation on the day. If you have any questions,
    please contact us on 0330 2233332.

    Patient must declare past medical history and fitness in order for safe treatment by The Regenerative Clinic. If not clearly declared, this poses serious risks to the patient's safety and can result in cancellation on the day.

    Personal Details

    Title *

    What procedure do you propose to have? *

    Your First Name *
    Your Surname *

    Date of Birth (dd/mm/yyyy) *
    Email *

    Please provide your mobile number *

    Your insurance company if you are claiming fees back

    About You

    Do you wear contact lenses?

    Any body piercings?

    Any loose teeth, crowns or plates?

    Your weight (kilograms) *

    Your height (centimeters) *

    Surgical History

    Have you ever been to The Regenerative Clinic before? YesNo

    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

    When was your last general anaesthetic (dd/m/yyyy)?

    Have you or a relative ever had a problem with an anaesthetic?

    Who had the problem? Yourself, a parent, grandparent etc.


    Have you ever suffered from asthma? *

    Please tick all that apply:

    Please give further details if you answered 'Yes' to the last question. Please include dates (dd/mm/yyy)


    Do you have any lung problems? (Include chronic diseases and shortness of breath) *

    Do you smoke? *

    Are you an ex smoker? *

    If yes, when did you stop?

    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 tick all that apply:

    Please provide any further information

    Obstructive Sleep Apnoea

    Do you suffer from Obstructive Sleep Apnoea? *


    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? *

    If yes, when?

    Do you get breathless when walking? *

    If yes, how far can you walk before becoming breathless in metres?

    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? *

    If yes, please give further details about your pacemaker?

    Have you ever had heart treatment such as defibrillation, coronary angioplasty, coronary stent insertion? *

    If yes, please provide details?

    Do you have any other heart condition not already mentioned above? *

    If yes, what do you have?

    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)? *

    If yes, what type of disease?


    Have you ever had liver disease? *

    Do you drink alcohol? *

    If yes how many units in one week (1 unit = 1/2 pint or one glass of wine)?


    Have you ever had pancreatitis? Please include cysts and pancreatic cancer *


    Have you ever had indigestion or stomach problems? * This includes reflux, heartburn and ulcers


    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? *

    Neck problems

    Have you ever had neck problems Please include trauma, ankylosing spondylitis and an increasingly stiff neck? *


    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? *

    If yes, what type of bleeding problem do you have?

    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? *

    If yes, what abnormal blood clotting disorder do you have?


    Have you had anaemia, blood problems or leukaemia? Please include sickle cell, thalassaemia and other inherited problems


    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)? *

    If yes, when?

    Do you suffer from fits/epilepsy? *

    If yes when was your last attack?

    Do you suffer from neck problems? *

    If yes please describe you neck problem?

    Mental Health and Memory Loss

    Have you ever had bipolar disease (depression), schizophrenia, claustrophobia, anxiety, aggrophobia or memory loss? *


    Have you an under or over active thyroid? *

    Medication and Drugs

    Are you taking any medication? Have you taken steroids in the last three months? Please include over the counter and recreational
    drugs, vitamins and Chinese herbs *


    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 tick if you have or have had any of the following infections

    Please tick if any of the below apply to you

    Please provide as much information as possible.


    Have you had falls? *

    Do you have mobility problems or need mobility aids? *

    Needle Phobia

    Do you have a needle phobia? *

    Additional Details

    If there is anything else that is not covered in the questions above, which you feel we should know, please give further
    details below:

    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

    Type your name below to accept*

    Your First Name *
    Your Surname *

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