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Pre-Op Questionnaire

To help plan the best medical care, please fill out this questionnaire and submit to Dr Dae-Soo Kim.

Pre-Operative Questionnaire

This questionnaire helps Dr Kim understand your medical history and current health status to ensure your safety during anaesthesia. Please answer all questions as accurately as possible.

Patient Information

Patient Name *

Patient Date of Birth *

Your Name *

Your Email *

Your Phone Number *

Procedure Information

Type of Operation You Are Having *

Surgical Item Numbers *

Date of Operation

Who is Your Surgeon? *

Which Hospital? *

Surgical & Anaesthesia History

Previous Operations

Have You Previously Had Any Problems with Anaesthetics? If yes, provide details below

Do You or Your Family Have History of Problems or Reactions with Anaesthetics?

Physical Measurements

What is Your Height in Metres (m)? *

What is Your Weight in Kilograms (kg)? *

Medical History

Heart History *

No Heart History High Blood Pressure Irregular Heart Beat Heart Valve abnormality Ischaemic Heart Disease Had a stent or Bypass in the past Heart Failure Other

Respiratory History (Lungs) *

No Respiratory History Bronchitis Pulmonary embolus Asthma Emphysema, CAL or COPD Recent Chest infection Other

Please Provide Details of the Heart and/or Lung Condition Above

Do You Have Sleep Apnea? *

Do You Have a CPAP Machine? *

Gastrointestinal Disease (eg reflux, stomach ulcer, crohns disease, other)? *

Neurological History (stroke, TIA, dementia, epilepsy, parkinsons disease)? *

Do You Have Diabetes? *

Do You Have Vascular Disease (blocked arteries or clots in the leg)? *

Do You Have a Blood Disorder? *

Please Provide Details of Any Other Medical Condition Not Mentioned So Far

Medications

Are You Currently Taking Any Medications (including over the counter and herbal medications)? Include Name and Frequency.

Do You Have Any Drug Allergies?

What is the Allergy?

What is the Allergic Reaction?

Are You Taking Any Weight Loss Medication Such as Ozempic? *

Lifestyle

Do You Smoke or Vape? *

How Many Cigarettes Do You Smoke Per Day?

Do You Drink Alcohol? *

How Many Standard Drinks Per Day on Average?

Do You Take Recreational Drugs? *

Please Detail Which Recreational Drugs You Take

Do You Regularly Exercise? *

What Type of Exercise?

Additional Information

Do You Have Any Other Concerns or Questions About Your Anaesthetic?

Your questionnaire has been submitted