Adult Preoperative Assessment Name * First Name Last Name Date of Birth * D/M/YYYY Have you ever had a previous general anaesthetic? Yes No If yes, were there any problems? Is there a family history of problems with general anaesthetics? Yes No If yes, please tell us more Do you have any other medical problems such as: Asthma Heart Disease Diabetes Other If yes, please specify Do you have any allergies to any medications? Yes No If yes, please list Do you or any of your family have any bleeding tendency ? Yes No If yes, please explain Do you have any loose teeth - if so which? Are you on any medications including herbal supplements? Yes No If yes please list below Please let us know if there is anything you would like the anaesthetist and surgeon know before the surgery? Thank you!
