Anesthesia Questionnaire
Date:

MonthName:
Date of Birth:MonthDD, 20YY

DD, 20YY

Height:cm

Weight:kg
Yes

No

Yes

No

4. Have you ever had surgery?

Yes

No

When?
(e.g. what year, years ago,or your age at the time)

Any difficulties
orcomplications
with anesthesia?

1. At this hospital, blood transfusions are performed if medically indicated. Do you consent to bloodtransfusion if necessary?
2. Can you climb one flight of stairs without having to take a rest?
3. Do you exercise regularly?

YesNoType of exercise:

Diagnosis / Type of SurgeryYes / No
Yes / NoYes / NoYes / No
5. Do you have any blood relatives who have experienced difficulties or complications during

Yes

No

6. Do you easily develop motion sickness?

YesNo

7. Have you ever smoked?

YesNo

YesNo

Yes

Noanesthesia? (high fever, cardiac arrest, etc.)①

If “Yes,” smokedcigarettes a day foryears; quit around Month②

If you are “presently smoking,” would you like to see someone at the smoking cessation clinic?

YYYY

8. Do you drink alcohol?
①

If “Yes,” →(How often)

daily,weekly,(What kind of alcohol)

occasionally(Amount per day)

9. Have you ever had an allergic reaction like a rash or itchiness with any of the following foods or other substances?
①

Food: avocado, kiwi, banana, chestnuts, other:

Yes

No

②

Medications: Name of medicine:

Yes

No

③

Disinfectants: alcohol, isodine (povidone iodine), other:

Yes

No

④

Rubber products: latex gloves, condoms, rubber bands, other:

Yes

No

⑤

Do you have any of these conditions: → Rhinitis / hay fever / allergic conjunctivitis
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Copyright © St. Luke's International Hospital All rights reserved.
English-language sentences shall conform to their Japanese-language counterparts.
Any legal responsibility involved shall be governed and construed based on Japanese-language sentences.

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10. Have you had any of the following? (Other than what you are having surgery for)If “Yes,” please circle (○) or write the diagnosis (name of disease) or other details.
① Neurologic / Psychiatric diseases: stroke, Parkinson’s, depression, schizophrenia, other:

Yes

No

②

Have you ever experienced convulsions / loss of consciousness?

Yes

No

③

Eye diseases: cataracts, glaucoma, artificial eye, other:

Yes

No

④

Heart / Cardiovascular diseases: hypertension, myocardial infarction, angina, valvular disease,

Yes

No

Yes

No

arrhythmia, pacemaker, other:⑤

Lung / Respiratory diseases: asthma, sleep apnea syndrome, emphysema, tuberculosis, interstitial
pneumonia, other:⑥

In case of “asthma,” most recent attack: Month⑦

Have you ever been told that you snore while sleeping?

YesNo⑧Endocrine diseases: diabetes, thyroid disorders, diabetes insipidus, other:

Yes

No

⑨

Gastrointestinal diseases: stomach / duodenal ulcer, liver disease, reflux, other:

Yes

No

⑩

Blood diseases: leukemia, anemia, other:

Yes

No

⑪Muscle, joint, and skin diseases: myasthenia gravis, muscular dystrophy, rheumatoid arthritis,

Yes

No

Yes

NoYes

NoDD, YYYY; Medication: Routine / Attacks only / Nonecervical spondylitis, atopic dermatitis, other:⑫

Urologic diseases: benign prostatic hyperplasia, renal failure, other:⑬Other disease(s) not mentioned above:

11. Do you take any medications prescribed / provided other than from this hospital?
If “Yes,” please provide the names of the other medicines you are prescribed and/or taking:If you do not know the names of the medicines, tell us why you take them, e.g. “2 different medicines for high bloodpressure.”If you are on any medications, you MUST bring something we can identify them with (a written list like yourMedication Notebook, the prescriptions, or the actual medications) when you come for your anesthesia consultation.

12. If you take any vitamins/supplements, over-the-counter medicines, or health foods, please write them here:

Continued on the next page →〒104-8560 東京都中央区明石町 9-1 Tel.03-3541-5151 Fax. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.
English-language sentences shall conform to their Japanese-language counterparts.
Any legal responsibility involved shall be governed and construed based on Japanese-language sentences.

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13. Questions about your oral care, teeth and dental treatments
Yes①

Do you have any dental issues?

②

If “Yes”, please circle (○) related symptoms below or describe what they are:Notoothache / pain of the gums / bleeding from the gums / loose teeth / dentures do not fit properly / Other:③

Do you see your dentist regularly?

④

When did you last visit the dentist?

⑤

Do you have any teeth which are presently undergoing treatment?

⑥

When is your next dentist appointment? Around Month

Around Month

YesNoYesNoYYYYYYYYLet us know the condition of your teeth using thediagram here:


LeftRightMark sites where you have no teeth with an “X”
Mark details such as those below:“Loose tooth”“Dentures”“Ceramic”“False tooth”“Implant,” etc.

If you have not been to the dentist within the past 6 months,
or if you have loose or bad teeth, we recommend you see adentist before your anesthesia consultation.

14. For women:①

Are you pregnant?

Yes

No

②

Are you presently breastfeeding?

Yes

No

15. If you have any questions about the anesthesia or surgery, or if you have any concerns you wish to discuss, pleasewrite them here:

Thank you for your cooperation.
220215_Ver.5.00_A4 白黒両面

〒104-8560 東京都中央区明石町 9-1 Tel.03-3541-5151 Fax. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.
English-language sentences shall conform to their Japanese-language counterparts.
Any legal responsibility involved shall be governed and construed based on Japanese-language sentences.

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