Best team of anaesthetists in Sri Lanka
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සිංහල
PREOP ASSESSMENT FORM
Please fill the form below prior to your surgery
Name
Date of birth
*
Weight (Approximately, if known)
Height (Approximately, if known)
Employment
Sex
*
Male
Female
Marital status
Married
Unmarried
Email
*
Phone
What is the surgery ?
*
Surgeon’s name
Do you suffer (or used to) from the following medical problems?
Diabetes Melitus
Bronchial Asthma
High Blood Pressure
Heart Disease
Other
If you suffer from heart disease
Have you been treated in a hospital for a heart problem ?
Have ever had heart attack ?
Yes
No
When was it diagnosed ?
Angina pectoris or chest pain while walking (how often ?)
Heart Failure
Yes
No
Heart rhythm disturbances
Yes
No
With how many pillows do you use to sleep at night?
How many stairs can you climb without getting shortness of breath ?
If you suffer from respiratory disease
What following condition/s do you have ?
Asthma
Emphysema
Pneumonia
Dyspnea
Bronchitis
Other
Have you been treated in a hospital for a respiratory problem?
Yes
No
Do you use inhaler ?
Yes
No
DIABETES MELLITUS
Do you receive insulin injections ? Dose & Time ?
Do you receive oral antidiabetic pills ?
Yes
No
RENAL DISEASE
Do you suffer from following kidney problems ?
Nephrolithiasis (Stones)
Urinary Tract Infection (UTI)
Renal Insufficiency
Other
Are you on dialysis ?
Yes
No
When was your last dialysis session before surgery ?
LIVER DISEASE
Do you suffer from following liver problems ?
Hepatitis
Cirrhosis
Jaundice
Other
BLOOD DISORDERS
Do you have following coagulation problems ?
Easy bruising
Hemophilia,
Platelet disorders,
Thalassemia
Anemia
Other
CEREBRAL DISEASE
Do you have ?
Cerebrovascular disease (Paralysis)
Epilepsy (Fits)
Headache
Other
THYROID DISEASE
Do you have thyroid disease ?
Yes
No
If yes, what is it ?
Hypothyroidism
Hyperthyroidism
Other
RECENT ILLNESS
Are you sick or have you been sick recently ?
Yes
No
Do you have following
Cold
Sore throat
Coughing
Fever
Influenza
I do not have any of above
Did you receive corticosteroids the last 12 months? (cortisone, prednisone, dexamethazone)
Yes
No
OTHER MEDICAL PROBLEMS (please explain)
Do you have artificial dentures, mobile teeth or crowns ?
Yes
No
Do you have trouble opening your mouth, swallowing or breathing at night?
Yes
No
SMOKING
How many years do you smoke ?
How many packs/week ?
Did you smoke in the past?
Yes
No
If yes when did you quit ?
Do you consume alcohol often ? (at least once a week)
Yes
No
How many glasses / day ?
Do you, or a relative suffer from muscle weakness ?
Yes
No
Option 3
Did you or a relative ever suffer from an anaesthesia-related problem ?
Yes
No
If yes, how?
Did you suffer from any reaction to topical anaesthesia at the Dentist’s clinic ?
Yes
No
If yes, how ?
Do you receive medication ?
Yes
No
If yes, complete the medication and dosage (aspirin included)
Did you ever manifest an allergic reaction to drugs or foods?
Yes
No
If yes, what kind of allergic reaction ?
Rash
Fainting
Breathing difficulty
Other
Have you undertaken any surgical procedure in the past ?
Yes
No
If yes, please complete type and date
Do you snore during sleep ?
Yes
No
Do you have loose teeth ?
Yes
No
Verification
Please enter any two digits
*
Example: 12
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