To help us determine if you are medically fit for anaesthesia and surgery, please complete this health questionnaire. It will take 5-10 minutes to complete and we ask you to give us as much detail as possible.

If you are unsure about any of the questions or having difficulty completing the questionnaire, please contact the clinic either by phone 01482 976980 or email info@thekarriclinic.co.uk and we will be happy to help.

All information you submit will be treated confidentially.

Patient Details

Title

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City Postcode

Email

Telephone(Required)

What is your job?

Next of Kin

Next of Kin Name

First Last

Next of Kin Telephone

Next of Kin Address

Street Address Address Line 2 City Postcode

Relationship to you?

Section 1: Cardiovascular System

Do you have, or have you ever suffered from any of the following conditions?

	Yes	No
Hypertension (high blood pressure) or hypotension (low blood pressure)
Angina/chest pain
Heart attack
If Yes was it within the last 6 months?
Palpitations (Irregular or fast heart beat)
Heart murmur
Do you have a pacemaker
Any other Heart Complaint?

Section 2: Respiratory System/ Endocrinology

Do you have, or have you suffered from any of the following conditions?

Section 3: Renal/Kidney/Liver/Anaemia

Do you have, or have you suffered from any of the following conditions?

	Yes	No
Kidney, bladder, or urinary problems
Are you receiving dialysis?
Have you ever had a transplant?
Liver disease or jaundice
Excessive bleeding/bruising
Blood clot / embolism/ Deep Vein Thrombosis (DVT) / clotting disorder
Anaemia (If yes, are you taking iron or other supplements?)

Section 4: Cerebrovascular

Do you have, or have you ever suffered from any of the following?

Section 5: Anaesthesia

Have you any of the following:

If yes to anaesthetic, please describe what operation and when?

Section 6: General Health

General health questions

Do you suffer from depression, anxiety, panic attacks, or mental illness?

Yes

No

If Yes, please describe below:

Do you see your GP regularly for any other reasons?

Yes

No

If Yes, why?

Do you smoke or vape?

Yes

No

If Yes, how many a day?

If No, have you smoked within the last 5 years?

Yes

No

How many units of alcohol do you drink per week? (a glass of wine or pint of beer is 2 units, single spirit is 1 unit)

Sickle cell trait/disease?

Yes

No

Are you on birth control?

Yes

No

If No, is there any possibility you may be pregnant?

Section 7: Medication

Do you take any regular medicines?

Yes

No

If Yes, please list name of the medicine, dosage and number of times a day you take the medication:

Section 8: Allergies

Do you have any allergies: (such as drugs, plaster, latex, nuts etc.)?

Yes

No

If Yes, please describe below:

Section 9: Any other information

Is there anything else you think the surgeon, anaesthetist or nurse should know?

Yes

No

If Yes, please describe below:

Please give the full name of the person who will be taking you home after surgery and looking after you for the first 24-48 hours.

Approximately how long is your car journey home from The Karri Clinic?

Sign

Patient Name(Required)

Signature(Required)

Date(Required)

Checking you’re real

Comments

This field is for validation purposes and should be left unchanged.

	Yes	No
Asthma
Sleep Apnoea
COPD
Bronchitis
Pneumonia
Underactive/Overactive Thyroid
Diabetes

	Yes	No
Stroke (CVA) - In the last 6 months
Mini stroke (TIA) – In the last 6 months
Muscle disease or progressive weakness
Epilepsy or fits

	Yes	No
Loose teeth
Anaesthetic for an operation?
You or a family member had problems with a previous anaesthetic?
Any dental work that we need to be aware of?

	Yes	No
Do have any problems with restricted neck or jaw movement?
Do you have any joint or arthritis problems?
Do you ever get heartburn?
Have you had an infection caused by MRSA?

PRE-OPERATIVE ASSESSMENT FORM

Patient Details

Next of Kin

Section 1: Cardiovascular System

Section 2: Respiratory System/ Endocrinology

Section 3: Renal/Kidney/Liver/Anaemia

Section 4: Cerebrovascular

Section 5: Anaesthesia

Section 6: General Health

Section 7: Medication

Section 8: Allergies

Section 9: Any other information

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