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DEPARTMENTS OF ANESTHESIOLOGY : PATIENTS' QUESTIONNAIRE

We require the following information about your medical history, as safe and correct administration of anesthetics depends on your current health.

1, Have you ever suffered from the following disease or conditions ?　　　Yes , No

If so, please circle.

Bronchial asthma, diabetes, hypertension, hepatitis, porphiria, tuberuclosis, reumatic arthritis, Hemophiria, angina pectoris, heart attack, arrythmia, cardiac valve disese,glaucoma, malignant hyperthermia, renal failure, anemia, cardio myopathy,

　 0ther？ please write here.( )

2, Have you ever had a drug or food allergy ?　 Yes, No

If so, what ? ( )

3, Are you taking any of the following ?　　　 Yes, No

If so, please circle.

Drugs for cardiac disease, hypertension, diabetes. hypnotic drugs, antibiotics, anticoagulant drugs, hormonal drugs (steroid),

Other drugs, please write here.( )

4, If you cut or injure yourself, does the bleeding stop normally ?　　　 Yes, No

5, Have you ever received anesthetics or had an operation before?　　　 Yes, No

If so, please write details here.

Age: ＿＿＿＿＿＿ Operation: ＿＿＿＿＿＿＿＿＿＿＿

6, If you have had an operation, did you have any problems with the anesthetic ?

Yes, No

7, Regarding your family medical history.

Dose anyone in your family have any problems with anesthetic ?　　　 Yes, No

Has anyone in your family suffered from ?

Cerebral stroke, heart attack, angina

If yes, what relation ? ＿＿＿＿＿＿＿＿＿＿

8, Have you ever had a blood transfusion ?　　 　 　　　　　　　　　 Yes, No

9, Do you permit us to do a blood transfusion in the case of an emergency ?

Yes, No

10, When you climb the stairs, does your heart pound or do you feel out of breath ?

Yes, No

11, Can you flex your neck backwards without dificulty?　　　 　　　 Yes, No

12, Can you open your mouth wide enough to insert three fingers vertically ?

Yes, No

13, If you smoke or drink, plesase tell us how much ?

＿＿＿＿＿cigallete a day

＿＿＿＿＿glasses of＿＿＿＿＿＿a day

( For women only )

14, Is there a possibility that you are pregnant ? 　　　　　　　　　　 Yes, No

( For people having an operation today )

15, When did you eat last ?

date:＿＿＿＿time: ＿＿＿＿＿

What did you eat ? ( )

Patient's signature

date ＿＿＿＿＿＿　　　＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

In case the patient cannot sign, the person who filled out this form, should sign here.

relation to patient ＿＿＿＿＿＿＿＿＿

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