Patient Name (required)
Do you use a continuous positive airway pressure (CPAP) device to help you breathe at night? please selectyesno
Do you snore loudly? please selectyesno
Do you feel tired, fatigued or sleepy during the day? please selectyesno
Has anyone observed you to stop breathing during your sleep? (Partners often report the person snores, then is silent for a few seconds) please selectyesno
Please tick all that apply: I have high blood pressure and / or I am taking tablets for hypertensionI have had anginaI have had a heart attackI have had heart bypass surgeryI have heart valve problems or had a valve operationI have heart failureI have or have had atrial fibrillationI have or have had other arrythmias (irregular heart beats)I have had an ablationI have an aneurysm or have had aneurysm surgery
Do you currently have any of the following? A pacemakerAn indwelling defibrillatorA plain stentA drug eluting stentA heart valve replacement
Please tick all that apply: Do you have renal failure (kidney failure)?Are you on dialysis?Have you had a kidney transplant?
If you are male, do you have prostate problems Frequency, poor stream, difficulty passing urine, getting up at night to urinate ? please selectyesno
Please tick if you have you had: Prostate cancerSurgery to remove your prostateRadiotherapyChemotherapyUltrasound treatment
Please tick all that apply: I have had jaundice (other than at birth)I have had hepatitisI have cirrhosisI have liver failure
Please tick all that apply: I have indigestion or heartburnI get a nasty taste and / or fluid in my mouth if I lie down or bend overI have had an endoscopy (camera investigation)I have or had an ulcerI have been diagnosed with refluxI have had surgery
Please tick all that apply: I have been on insulinI have been on diabetic tabletsI have had low blood sugar ('hypos') in the last yearMy diabetes is well controlledI have had my eyes examined in the last yearI have kidney complicationsI have diabetic leg ulcers or poor blood supply in my legs
Please tick all that apply: I have a painful neckI have a stiff neckI have had a whiplash injuryI have rheumatoid arthritis affecting my neckI have ankylosing spondylitisI find it difficult to look up or look behind meI have had neck surgery or injections into the spine
Please tick all that apply: I have had a deep vein thrombosisI have had a pulmonary embolusI have been on anticoagulants (blood thinners)I am still on anticoagulantsI have a clotting problem such as factor V LeidenI bleed or bruise easily and have a bleeding problem such as haemophilia or factor X deficiencyI am under a haematologist
Please tick all that apply: I have had low iron or anaemiaI am currently anaemicI take iron tabletsI have had leukaemia or lymphomaI am sickle traitI have sickle diseaseI am thalassaemia traitI have thalassaemiaI have a family history of these problems but have not been testedI am under a haematologist
Please tick all that apply: I have had fitsI am currently epileptic and/or take drugs to control fitsI have had a strokeI have had or may have had a mini stroke (transient ischaemic attack)I have had brain surgeryI have had a head injury requiring intensive careI have seen a neurologist
Please tick all that apply: I have suffered from bipolar disease / depressionI have schitzophreniaI have been under a psychiatristI suffer from claustrophobiaI have memory lossI need my partner or family to help me make decisions
Please tick all that apply: I have an underactive thyroidI have a specific diagnosis (e.g. Hashimotos, Graves)I take thyroxineI have an overactive thyroidI have had a thyroid mass or thyroid surgery
IF YOU ARE ON THYROXINE PLEASE ASK YOUR GP FOR YOUR LATEST BLOOD TEST AND BRING IT INTO HOSPITAL
Please give further details if you answered 'yes' to the last question Please include dates
I confirm the above information to be true to my best ability. I understand that the information used here is for the purpose of my admission to hospital. I understand that I am responsible for the accuracy of the information given and I am aware that this is used for my procedures’ anaesthetic purpose. I am aware that a nurse will be forwarding this information onto my anaesthetist and that the nurse may contact me to go over any of the information that I have provided.
Please write your name below to confirm acceptance
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+44 (0)20 3075 2345
