Anaesthesia Form

Dr Chow Chow Pain Specialist and Anaesthetist

To optimise your anaesthesia for the day of your surgery, we will need some background information from you. The information you provide will allow us to provide the excellent perioperative care.

Name

Birthday

Height

Weight

Proceduralist Name

Name of Surgery

Date of Surgery

Please tick any of the following that apply to you:

Ischaemic Heart Disease or Previous Heart Attack Heart Valve Disease Pacemaker or Defibrillator COPD, Chronic Bronchitis, Emphysema Current Smoker (including cigarettes and cannabis) Sleep Apnoea Diabetes Chronic Kidney Disease Chronic Pain on Opioids Uncontrolled Gastric Reflux Anxiety Taking Blood Thinner (except Aspirin)

Your current medication list

Allergy

Anaesthetic History

I had General Anaesthetic (GA) previously. I had difficult venous access. I had severe post operative nausea and vomiting. I had severe post operative pain. I had significant anaesthetic bad event previously. I have been told I might have "Malignant Hyperthermia" gene. I have been told I have difficulty with ventilation or intubation. I have no problem with anaesthesia. This will be my first anaesthetic.

Do you have any question or comment?

Remember: No food or drink from midnight. You can drink WATER 2 hours before coming to hospital. Strictly NO coffee or chewing gum before surgery.

DR CHOW CHOW

Thank you for submitting the consultation form. We look forward to seeing you at your appointment.

If you would like to upload further information or talk to one of us, please contact

ANAESTHESIA FORM

DR CHOW CHOW

info@drchowchow.com 02 8866 1393

info@drchowchow.com
02 8866 1393