Gelenk Klinik Orthopaedic Clinic
Alte Bundesstrasse 58
D-79194 Gundelfingen
Germany
fon: +49-761-79117-228
fax: +49-761-79117-999
care@joint-surgeon.com

Medical Questionnaire in Preparation for Anaesthesia

General Anaesthesia Combines Safety with Stress Reduction ©Viewmedica

This questionnaire is for patients planning orthopaedic surgery at the Gelenk-Klinik Hospital in Germany. Please complete the form once you have requested a surgical appointment at our clinic.

Why is it important to complete this form?

Every anaesthetic procedure can have risks and side effects. The safety and comfort of our patients are our highest concern. The duty of the anaesthetist is to keep you safe at all times during your orthopaedic procedure.

In order to be able to avoid risks, it is important that you answer the questions below. If following this questionnaire, further information is required from you, the anaesthetist will contact you with further questions.

The anaesthetist will make recommendations in preparation for your procedure. A thorough and diligent follow-up to this questionnaire increases your safety and is important for the positive outcome of your procedure.

If you have any concerns about the private nature of any of the questions below, you may choose to postpone this interview until you arrive in our clinic (if this is the case, please tell us, so that this can be noted on your file).

First Name of Patient *

Family Name of Patient *

E-Mail-Address of Patient *

Date of Birth of Patient *

Month

Day

Year

Street-Name, House No *

City *

Country *

Date of your surgical appointment? (only if you already have one)

Month

Day

Year

Department and type of your planned surgery *

Height (cm) *

Weight (kg) * kg

Your Occupation *

Do you wear a hearing aid? *

yes

prefer not to answer

Do you wear contact lenses? *

yes

prefer not to answer

Do you have gum disease/dental decay or false teeth? *

yes

prefer not to answer

Do you have any foreign material implants in your body? *

yes

prefer not to answer

(cardiac pacemakers, prostheses, stents, hormone coils, piercings)

Have you been under medical care recently? *

yes

prefer not to answer

If yes, please give the the reason for the medical care

Do you currently have an infection? *

yes

prefer not to answer

(Cold, stomach infection, bowel infection etc)

Do you take any regular medication? *

yes

prefer not to answer

(Medication for heart, pain, sleeping, anti coagulants, antidiabetes, psychopharmaceuticals or other preparations that you buy over the counter in your pharmacy)

If you take regular medication please give medication name and dosage

Have you had any previous surgery? *

yes

prefer not to answer

If yes please indicate the procedure and date of the surgery?

Have you ever had any complications to anaesthesia? *

yes

prefer not to answer

If yes please indicate type of complications?

Have you ever had any complications from a blood transfusion? *

yes

prefer not to answer

Have any of your blood relatives had complications to anaesthesia? *

yes

prefer not to answer

Would you like to give any details about the above or any other diseases and disorders?

Do you or any blood relative have muscular disease? *

yes

prefer not to answer

(Genetic disposition, weakness, please also indicate if your blood relatives have such a condition)

Do you have any other relevant health factors that we should know about?

(Please indicate accidents, job related health risks, severe injuries, allergies)

Do you smoke cigarettes (cigars or pipe) *

If female: is there any possibility you could be pregnant? *

yes

prefer not to answer

Legal Disclaimer and Confidentiality

Personal data provided will not be disclosed to third parties. Your information will be stored and used only for the fulfillment of the stated purpose of contact and in order to respond to your enquiry. Your data is subject to medical confidentiality. The transmission of data to the medical staff is via e-mail. This is subject to normal e-mail distribution risks and the risk of data corruption. The identity of the sender can not be verified by us. Communication via this form is therefore not legally binding for either party. This service is provided by us in order to facilitate and prepare for medical investigation and medical treatment. The service does not constitute or replace a face to face medical check up, or treatment by a qualified physician. Any electronic communication by us resulting from this data, is to be treated as general information. In order to act upon this information, please consult your local physician, until such a time that you have been examined by the medical team at the Gelenk Klinik.

Did you read the disclaimer and accept the confidentiality agreement? *

Yes I agree

Do you have any questions or concerns?

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Medical Questionnaire in Preparation for Anaesthesia

Why is it important to complete this form?

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