Background Health Questionnaire and Informed Consent Form for Procedural

Esteemed Patient!

The following questions provide critical medical background information for the safe and proper
administration of anesthesia required for your medical procedure(s). We kindly ask that you take the time to
fill it out as accurately and completely as possible providing all pertinent medical background information for our anesthesiologist to best perform their procedure(s) and providing you, or the patient, with the highest standard of care possible. Any omissions or inaccurate information could expose you, or the patient, to unnecessary dangers. If anything is unclear regarding the questions below, please consult the anesthesiologist prior to answering the form.

Mother’s Maiden Name

Emergency contact name

Emergency contact phone nr

Individual characteristics

Have you been treated by a doctor recently?

Yes

Do you take any medication regularly?

Yes

If yes: what and how often?

Have you ever been placed under anesthesia?

Yes

Were there any complications?

Yes

Has anyone in your immediate family had any complications from anesthesia?

Yes

Have you ever been given blood

Yes

or blood product?

Yes

Do any of the ailments below pertain to you?

Heart disease: (heart attack, angina, heart failure, shortness of breath during physical activity (eg, walking up stairs), inflammation of cardiac muscle, heart rhythm disorders)

Yes

Circulatory & Vascular Disease: High or low blood

Yes

Lung & Respiratory Disease (Tuberculosis, pneumonia, Asthma, etc)

Yes

Liver Disease (jaundice, Hepatitis)

Yes

Kidney & Urinary Disease (pyelitis, kidney or bladder stone)

Yes

Diseases of the Digestive System: (ulcer, pancreatitis, biliary stone(s), chronic intestine disease )

Yes

Metabolic disease: (eg: diabetes)

Yes

Thyroid disease: (Struma)

Yes

Eye problems: (glaucoma)

Yes

Neurological disease:

Yes

Have you ever received any psychiatric care? (eg: depression)

Yes

Bone or Joint Disease: (vertebral disc herniation, gout, arthritis)

Yes

Muscular Disease: (among relatives)

Yes

Coagulation Disorder: (frequent bruising including after smaller interventions on the skin, joint bleeding, frequent nose bleed)

Yes

Allergy: (medicine, latex, food etc)

Yes

Other disease: (immune diseases, skin disease,umour, poisoning, etc.),

Yes

Dental replacements: (crown, bridge, removable denture,etc)

Yes

Removable dentures

Yes

Are you pregnant?

Yes

Do you consume alcohol regulary?

Yes

29. Do you smoke?

Yes

Do you have hearing aid(s)?

Yes

Do you do regular physical activity?

Yes

I consent to the release of my above health data to my companion

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Background Health Questionnaire and Informed Consent Form for Procedural

Ossza meg ismerőseivel!

Kérdése van? Időpontot szeretne foglalni?
Írjon nekünk gyorsan és egyszerűen, pár pillanat alatt.
Munkanapon 24 órán belül válaszolunk megkeresésére!

Background Health Questionnaire and Informed Consent Form for Procedural

Ossza meg ismerőseivel!

Kérdése van? Időpontot szeretne foglalni? Írjon nekünk gyorsan és egyszerűen, pár pillanat alatt. Munkanapon 24 órán belül válaszolunk megkeresésére!

Kérdése van? Időpontot szeretne foglalni?
Írjon nekünk gyorsan és egyszerűen, pár pillanat alatt.
Munkanapon 24 órán belül válaszolunk megkeresésére!