Paediatric Preoperative Assessment Name * First Name Last Name Date of Birth D/M/YYYY Sex Has your child 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 list Does your child have any allergies to any medications? Yes No If yes, please list Are there any bleeding disorders in the family? Yes No If yes, please explain Does your child have any other medical problems such as: Asthma Heart Disease Diabetes Other If 'Other' please specify Is your child on any other medication? Yes No If yes, please list Does your child have any loose teeth? Yes No If yes, which? Do you have any 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? Any additional comments? Thank you!
