Download Prijeoperacijski upitnik za elektivne kirurške pacijente

Pre-operative questionnaire
This questionnaire is comprised of the following:
•
Questionnaire on health conditions which is completed by the patient;
Guidelines for patients
The purpose of this questionnaire is for you to help us provide you with the best possible care prior,
during and after your stay in the hospital.
•
It is important that all parts of the questionnaire are completed as precisely as possible. All
information which is collected in the questionnaire will be used exclusively for your safety, and will
be considered secret.
•
Please return the filled out questionnaire to the administrator/nurse in the institution which
provided the questionnaire as soon as possible.
•
When you return the questionnaire to the administrator/nurse, you will be contacted by the phone
or e-mail to arrange the details of your admittance to the hospital. In case there is any
modifications in your contact information (telephone, address, e-mail), please inform us thereof at
the earliest moment, so that we would be able to reach you any time.
•
Do not forget to bring along to the hospital any medications you might be taking at this time,
important discharge summaries as well as x-ray imaging/CT/MRI scans and test results related to
your present condition.
•
Basic personal documents will also be required in the hospital, including your health insurance
card and additional or supplementary health insurance cards.
•
You are kindly asked to leave all your valuables at home instead of bringing them to the hospital.
1
BASIC PERSONAL INFORMATION
FIRST AND LAST NAME:
Date of birth:
Address:
Town / Country:
Telephone / E-mail:
BASIC MEDICAL INFORMATION
Sex:
Male
/
Body weight:
Female
Have you taken any medications over the last year?
Name of the medication
Dosage
YES
NO
How many times a day/week
What health problem is the reason you have to undergo hospital treatment?
What is the surgery / procedure you are expecting?
2
Do you have any allergies? (allergy to medications, food, latex, iodine, contrasts, other)
YES NO
If “yes”, please state what you are allergic to and what allergic reactions you suffer from
(rash, itching, choking, cardiac arrest, shock etc.)
Are you pregnant? (completed by women of reproductive age)
YES
NO
Have you ever been treated for excessive haemorrhaging?
YES
NO
Have you ever received a blood transfusion?
YES
NO
Do you refuse transfusion of blood or blood-based products?
YES
NO
(if “yes”, please enclose a written statement thereof, certified at a public notary’s office)
Have you or any members of your family had complications with anaesthesia? YES
NO
If “yes”, please give details:
Do you smoke?
YES
NO
YES
NO
Do you regularly take any herbal medications? (ginkgo, ginseng, garlic etc).
If “yes”, please state which ones:
YES
NO
Have you had high temperature, fever, cold or the flu over the last month?
YES
NO
Have you been seriously ill over the last 2 years?
YES
NO
If “yes”, please state how many cigarettes/packs a day:
Do you drink alcohol?
If “yes", please state the type of alcohol, quantities and how often you drink:
If “yes”, please give details:
Please state any previous surgeries (if any) and the time of the surgery (example, 1997):
3
THIS PART OF THE QUESTIONNAIRE IS COMPLETED BY THE PATIENT. IF
NECESSARY, PLEASE CONSULT YOUR GENERAL PRACTITIONER.
QUESTIONNAIRE ON HEALTH CONDITION
Do you or did you ever suffer from?
High blood pressure?
YES
NO
Angina pectoris or chest pain?
YES
NO
How often?
Heart attack?
YES
NO
When?
Some other heart condition?
YES
NO
Which one?
Pulmonary disease which resulted in
hospitalization?
YES
NO
Which one?
Lack of air?
YES
NO
Lack of air after climbing to the first floor?
YES
NO
Lack of air when lying on a flat surface?
YES
NO
Chronic bronchitis?
YES
NO
Asthma?
YES
NO
Do you use a pump (for example, Ventolin,
Serevent)?
YES
NO
Which one?
Some other pulmonary disease?
YES
NO
Which one?
Diabetes?
YES
NO
Do you use insulin?
YES
NO
Do you take any pills for diabetes?
YES
NO
Ulcer (ulcus) of the stomach or duodenum?
YES
NO
Hiatal hernia or heartburn?
YES
NO
Epilepsy?
YES
NO
Last seizure:
Brain attack (stroke, brain insult)?
YES
NO
When?
4
Which one?
Which one?
Loss of consciousness?
YES
NO
Thrombosis or embolism?
YES
NO
What of?
Do you take any anti-coagulant
medications?
YES
NO
Which one?
Hepatitis or liver condition (jaundice)?
YES
NO
Which one?
Kidney condition?
YES
NO
Which one?
Thyroid disease?
YES
NO
Which one?
Have you ever been given steroids?
YES
NO
Which one?
Any hereditary (family) diseases?
YES
NO
Which one?
Depression / other psychiatric conditions?
YES
NO
Rheumatoid arthritis?
YES
NO
Any neck or back problems?
YES
NO
Can you open your mouth fully?
YES
NO
Do you have any difficulties with breathing
through the nose?
YES
NO
Do you have any other health problems
which have not been mentioned so far?
YES
NO
Which one?
Do you wear contact lenses?
YES
NO
Which ones?
Do you wear a hearing aid?
YES
NO
Do you have removable dentures?
YES
NO
YES
NO
(for example, Decortin, Medrol)
Are you currently taking any?
What kind?
If “yes”, please state the type of denture
(upper, lower, partial, total dentures, both):
Do you have any loose or damaged teeth?
5
Which one?