Anacare
Ph: 07 41282550, 127 Torquay Rd Scarness QLD 4655

Patient Questionnaire

Please take your time to complete this Patient Questionnaire.  It is important that you complete this questionnaire as accurately as possible for consideration by your Anaesthetist, prior to your appointment.  If you are unsure of any information, please contact our staff as AnaCare between 9-3.00pm weekdays on (07) 4128 2550 for assistance.

When you have completed the form, simply press the Submit Form button at the bottom of the questionnaire and it will be automatically submitted to AnaCare.

Pre-Operative Assessment Questionnaire

     

     

Yes    No

Yes    No

 

Do you currently have, or have ever had, any of the following conditions?
(please tick all that apply)

Cardio Vascular Disease:

Respiratory Disease:

Blood Disease:

Have you taken any of these within the past 5 days:

Central Nervous System Disease:

Gastro Intestinal Disease:

Endocrinal Disease:

Muscular Skeletal Disease:

Please answer the following yes/no questions:

Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Yes    No

Do you wear or have any of the following (please tick):

Yes    No