Health Questionnarie

    1. Patient Details

    2. Questionnaire

    The information you will provide is confidential and is important to ensure your safety. Please answer the following questions carefully and honestly. If you have any difficulties with answering any of the questions below please leave it blank and ask the physician for help. The following information is collected to help us to choose the right treatment and an appropriate type of anesthesia for you before surgery.

    3. General Questions

    Are you generally in good health?*

    Have you been treated in a hospital in the last two years?*

    Do you have a chronic illness?*

    Do you take any medications on a permanent basis?*

    Have you taken any medications in the last 6 months?*

    Do you have any allergies?*

    Have you ever been hospitalized?*

    Do you smoke?*

    Do you take dietary supplements, herbs etc. (especially St John's wort, nettle, calendula, horsetail)?*

    Do you have cardiovascular problems (previous myocardial infarction, coronary heart disease, heart failure, arrhythmia, myocarditis, etc.)?*

    Do you have thyroid disease?*

    Do you have any blood or clotting problems?*

    Do you suffer from cancer?*

    Do you have any of the following infectious diseases listed below?

    a) Hepatitis A (infectious jaundice A)*

    b) Hepatitis B or C*

    c) AIDS*

    d) Tuberculosis*

    e) Venereal diseases*

    4. Additional Questions for Women

    Are you pregnant?*

    Are you on a pill (contraception)?*