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PRE-OPERATIVE ASSESSMENT QUESTIONNAIRE – CHILD
Please complete and fax or post back to our office


Name:

Date of birth:

Sex:


1. Has your child had a previous general anaesthetic?

YES / NO

If yes, were there any problems?



2. Is there a family history of problems with general anaesthetics?

YES / NO

If yes, please give details.



3. Does your child have any allergies to any medications?

YES / NO

If yes, please list.



4. Are there any bleeding disorders in the family?

YES / NO

If yes, please explain.



5. Does your child have any other medical problems such as:

a) Asthma?

b) Heart disease?

c) Diabetes?



6. Is your child on any medication?

YES / NO



7. Does your child have any loose teeth?

YES / NO

If yes, which?



8. Do you have other children at home?

YES / NO

If yes, is there anyone else at home who will be able to take care of them on the first night after your child’s operation?

YES / NO




You may find it helpful to have some Calpol and Neurofen at home as this will save you buying it at the hospital. We will provide you with the necessary dosage regime.