Due to the anesthesia, which you will receive for an operation, it is very important to complete the questionnaire. Please fill it in completely and carefully, an incomplete questionnaire could lead to a postponement of your operation. Put a cross in the box Yes, No or Unkown and write down any additional information if necessary.
Has your child ever had anesthesia?
If yes, what year and for what kind of operation?
_____________________________________________________________________________
Did your child have any problems with the anesthesia?
If yes, what kind of problems?
_____________________________________________________________________________
Has your child had ever any problems with local anesthetics?
If yes, what kind of problems?
_____________________________________________________________________________
Did your child bruise abnormally quick or bleed exeptionally long from skin defects?
Are there any kown family blood diseases in your family?
If yes, what kind?
_____________________________________________________________________________
Have there ever been any abnormalities found at the paediatric clinic (consultatiebureau) or at the schooldoctor?
If yes, what for?
_____________________________________________________________________________
Has your child been treated by the General practitioner (huisarts) or a specialist in the last year?
If yes, which one(s)?
_____________________________________________________________________________
Does your child use any medication?
If yes, which one(s)?
_____________________________________________________________________________
Had your child recently been in
contact with contagious diseases in other children or adults?
If yes, which disease(s)?
_____________________________________________________________________________
Is your child allergic or overly sensitive to any substance(s) or medication?
If yes, which one(s)?
_____________________________________________________________________________
My child weighs ___________ kg and is ___________ cm tall.
Date: ______________________Signature: ______________________
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