Asklepion – Clinic and Institute of Aesthetic Medicine, Londýnská 160/39, Praha 2
Phone:+420 234 716 000, 234 716 111, 602 483 322, www.asklepion.cz, info@asklepion.cz
Questionnaire
Surname:........................................................................................
Name:......................................................D.O.B.:...........................................
Address:............................................................................................................. ...........
....................................Phone:..............................................
Weight:...................................... Height:..................................
Requested
surgery:.........................................................................................................................
Which operation have you had in the past and what anesthesia was used (local – regional – general)?
………………………………………………………………………………………………………………………………………………………………………………………………
Are you aware of any complication during or after the operation(s) – (describe them):
1. Are you treated for heart disease (shortness of breath, chest pain, swelling of the legs,
have you had a heart attack, do you have a heart rhythm disorder, Angina pectoris)?
State the medication you use and its dosage:
YES
NO
2. Are you treated for high blood pressure (how long)?
State the medication you use and its dosage:
YES
NO
3. Do you suffer from asthma?
State the medication you use and its dosage:
YES
NO
4. Did you have pulmonary tuberculosis, pneumonia?
State the medication you use and its dosage:
YES
NO
5. Are you treated for diabetes mellitus (diet, tablets insulin)?
State the medication you use and its dosage:
YES
NO
6. Are you treated for thyroid gland problems?
State the medication you use and its dosage:
YES
NO
7. Have you had a treatment of renal disease (infections, kidney stones)?
State the medication you use and its dosage:
YES
NO
8. Do you have prostatic problems?
State the medication you use and its dosage:
YES
NO
9. Have you had a treatment of hepatic disease (hepatitis, mononucleosis)?
State the medication you use and its dosage:
YES
NO
10. Do you have gastric or duodenal ulcer or problems with pancreas?
State the medication you use and its dosage:
YES
NO
YES
NO
12. Do you have varicose veins, phlebitis (thrombosis, ambolization) ?
State the medication you use and its dosage:
YES
NO
13. Did you ever use hormonal medication as Prednison, Cortison....?
What kind, when and why?:
YES
NO
14. Are you treated for glaucoma?
State the medication you use and its dosage:
YES
NO
15. Are you allergic to anything? .............................................................................. YES
State the medication you use and its dosage:
NO
16. Have you ever had prolonged bleeding (nose bleeding, after tooth extraction or injury)?
When was the last time?
YES
NO
17. Have you ever had an oncology treatment, have you had a radiation treatment?
When and why?
YES
NO
11. Do you have a neurological disease (epilepsy, myasthenia, headaches, paralysis of
nerves, condition after stroke, borreliosis, operation of spinal discs) ?
State the medication you use and its dosage:
18. Have you had a surgery in general anaesthesia? Are you aware of any complications
during or after the surgery? vomiting, nausea, huskiness, changes in heart beating,
change in blood pressure, others…………….
YES
NO
20. Have you ever received a blood transfusion? Did you have any unusual reaction?
What kind and when?
YES
NO
21. Do you have a feeling of stiffness around your mouth after drinking coffee?
(Similar to pins and needles)
YES
NO
22. Do you have loose teeth or removable dentures or bridges or other implants (breast´s)?
YES
NO
23. Do you smoke, drink alcohol or do you have any other addictions (sleeping pills, drugs)
How many cigarettes daily?.......
How much alcohol daily? ………………….
YES
NO
24. Do you have any other untreated problems, not yet mentioned?
What kind and what treatment you use?
YES
NO
25. Are you pregnant? Do you take hormonal contraception?
What kind and how long?
YES
NO
26. Have you ever been or were you treated for mental disorder?
State the medication you use:
YES
19. Did anyone of your blood relatives have complication during or after anesthesia?
(for ex. sudden death) Details:……………..
NO
During the pre-op examination you can ask any question regarding the anesthesia and pain control after the surgery and you can also
list any conditions that may be from your point of view important. On your request you can be also informed about rarely occurred
risks or complications.
PLEASE FOLLOW THOSE INSTRUCTIONS
1. To avoid aspiration of contents of the stomach it is important not to eat and drink at least 6-8 hours before the planned surgery.
2. Do not smoke at least 6 hours before the surgery.
3. Removable dentures and/or contact lenses should be removed and safely kept.
4. Do not use make-up and nail polish.
5. Please put your watch and jewels to the safe in the department.
6. In the morning before the surgery the best please evacuate properly.
7. In case of menstruation please notify the staff ot the clinic. During big planned surgeries (such as Tummy tuck, Augmentation) is not suitable to
operate during first three days of the period.
8. For safe surgery in general anesthesia it is not recommended to use hormonal contraception. After consultation with gynecologist
it is advisable to discontinue using two months before the surgery.
I agree with the surgery in local – conduction – general anesthesia as an out patient.
I have read and understood to all information and I am able and willing to follow the instructions and recommendations.
I was informed about all the risks and possible complications.
Date:………………………………………………………
Signature of the client: ………………………………………………………………………………..