CENTRE HOSPITALIER PANAFRICAIN GSA (CHP-GSA)

DEPARTMENT OF ANESTHESIOLOGY
Questionnaire to be completed by the prospective surgical patient(s). The information given will assist the
anesthesiologist in providing the patient with the best care possible or procedure, which will enhance the success
of the operation and the patient recovery.

The questions are to be answered with YES or NO by making a cross. Fill in information of the first line.

Date_______________ ; Length_________________; Weight__________________; Age____________years

YES NO
Are you on medication? (If yes state the name in column 1) at the end of questionnaire.
Are you on or using anticoagulants (against blood clotting)
Were you ever seriously ill? (If yes, which illness, fill in, in column 2)
Have you ever had surgery? (If yes, fill in which operation in column 3)
Are you under the care of a heart specialist?
Are you presently under the care of an internist?
Are you under the care of a lung specialist?
Do you have high blood pressure?
Did you ever had pain in the chest?
Do you have a heart disease or problem?
Do you have or are suffering from a lung disease?
Have you ever suffered from any of the following illnesses?
* Heart attack
* Diabetes
* A stroke
* Epileptic seizures
* Disease of the thyroid gland
* Thrombosis
* Jaundice
* Sickle cell crisis

How many cigarettes or cigars do you smoke per day?

How many glasses of alcoholic beverages do you use per day?
Do you use drugs?
Are you allergic to any substance or medication? (fill in name in column 4)
Are you pregnant?
Have any of your relatives or family members had an abnormal reaction from
general anesthesia, local or regional anesthesia?
If possible do you prefer local or regional anesthesia than general anesthesia?
1. 2. 3. 4.

Douala, _____________________20_____ Patients name_____________________

Room no.: __________________________
Signature patient__________________