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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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?