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 high blood pressure?
Do you suffer from asthma?
Did you have pulmonary tuberculosis or pneumonia?
Have you been or are you being treated for diabetes mellitus?
Are you treated for thyroid gland problems?
Have you had a treatment for renal disease (infections, nephrolithiasis)?
Do you have prostate problems?
Have you had a treatment for hepatic disease (hepatitis, mononucleosis)?
Do you have a gastric or duodenal ulcer?
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)?
Do you have any sleeping problems?
If the answer is yes, please specify (snoring, tiredness after awaking, falling asleep during day, apneusis, sleep apnoea):
Do you consider yourself under stress at present?
Have you ever used hormonal medications (Prednison, Triamcinolon, Cortisone)?
Any possibility of pregnancy or are you attempting to get pregnant?
Number of Previous Childbirths:
Caesarean Section (number and year):
Are you taking birth control pills?
Are you being treated for glaucoma?
Have you ever had prolonged bleeding (after a tooth extraction, nose bleeding, after injury)?
Have you ever had a blood transfusion?
Please specify the reasons if you refuse a blood transfusion (Jehovah’s witness etc.).
Have you ever had any screening for cancers?
Female: Cervical Cancer by smear test
Have you ever had treatment in oncology?
Did you lose weight in last year?
How long do you have the same and stable weight?
Did you have radiation treatment?
Did anyone of your blood relatives have complications during or after operation (e.g. unexplained death)?
Do you have any feeling of stiffness around your mouth after drinking coffee?
Do you have any loose teeth or removable dentures or bridges?
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)
Are you allergic to something?
Do you have any food allergies?
Do you have any untreated medical problems?
What kind of medications are you using at present?
For weight loss treatment: Visit to psychologist and/or psychiatrist?
Hospitalisation in mental hospital (When, how long, why):
Psychiatric medication (When, how long, for what reason and what type of psychiatric medication.)
Do you suffer from any eating disorder? (Mental bulimia or any other?)
Any history of alcohol/drug abuse?
Do you need any special assistance/care/facilitation for your stay at the clinic?
Have you had Covid-19? If your answer is yes, please specify when.
Have you been hospitalized with Covid-19? If your answer is yes, please specify when.
Are you Covid-19 vaccinated?