What kind of operation are you going to have?
What operation(s) have you undergone in the past and in what year?
What type of anaesthesia was used (local – regional - general)? (If known)
Have you suffered from any complications during or after the operations - describe them:
Do you suffer from any local or general anaesthetic problem – describe them:
How was your scarring after the operation? (a thin line, a coloured scar, a raised lump on the skin, or specify if other)
Check YES or NO what is appropriate. If the answer is YES, provide the details.
Have you been or are you being treated for a heart disease?
Have you been or are you being treated for diabetes mellitus?
Have you had a treatment for renal disease (infections, nephrolithiasis)?
Have you had a treatment for hepatic disease (hepatitis, mononucleosis)?
Do you have varicose veins, phlebitis (thrombosis, embolisation)?
How often do you drink alcohol? Please specify.
Do you have a neurological disease (epilepsy, myasthenia, headaches, paralysis of nerves, condition after stroke, borreliosis, or operation of spinal discs)?
Have you ever used hormonal medications (Prednison, Triamcinolon, Cortisone)?
Number of Previous Childbirths:
Caesarean Section (number and year):
Have you ever had prolonged bleeding (after a tooth extraction, nose bleeding, after injury)?
Have you ever had any screening for cancers?
How long do you have the same and stable weight?
Do you smoke, drink alcohol or do you have any other relevant habits (e.g. taking sleeping pills)?
If you smoke at present, how many cigarettes a day do you smoke?
If you have stopped smoking – when did you stop? (month, year or both)
If you drink alcohol, how many units do you drink per week? (one unit = half a pint of beer or one small glass of wine, one single measure of spirits)
What kind of medications are you using at present?