Consent For Anesthesia Services

NaCl 0,9%
Rapifen
Propofol
Esmeron
Ultiva µg/min
O2
Sevofluran exp.
pCO2
SaO2
Atmung
200
Datum
:
Diagnose
:
Operation
:
OP-Gruppe
:
AN-Gruppe
:
Zugang
:
Tubus/LM
:
Lagerung
:
Besonderh. :
150
100
ⓒ 2003 Anästhesiepraxis Regenbogen
50
Postop. Uhrzeit: __________
Atmung suffizient
Kreislauf stabil
Bewußtsein orientiert
Schmerz: frei oder moderat
Surname:
.........................
Date of birth.: .........................
occupation: ............................
Given name : .........................
Street:
phone No.: ...........................
Age:
Zip Code. : .........................
......... cm ......... feet
City:
family physician: ........................
.........................
(1ft =30,48cm)
Weight :
...........kg ......... pound
(1pound=0,454kg)
Consent For Anesthesia Services
I consent to the anesthesia service for the sceduled surgery in form of general anesthesia, local anesthesia or a
combination of both for me / my child. It has been explained to me that all forms of anesthesia involve some risks and no
guarantees or promises can be made concerning the results of my procedure or treatment. I am familiar with the common
risk of anesthesia such as throat pain, injury to mouth and teeth, injury to blood vessels, nausea and vomiting.
I acknowledge that I have read and understood the anesthesia information form or had it read to me, that I understand the
risks, alternatives and expected results of the anesthesia service and that I had ample time to ask questions and to
consider my decisions.
_______
____________________
______________________
Date
Patient‘s Signature
Anesthesiologist‘s Signature
to be filled out by patient
Height:
........Years
.........................
Pre-Anesthesia Questionnaire
ⓒ 2003 Anästhesiepraxis Regenbogen
Please answer the following questions. These responses will help us provide
the optimal care and treatment
YES No
Did you have an operation before? What and when?


Have you or any blood relatives had difficulties with anesthesia? Which?


Are you on any medication? Which?


Do you currently have a severe cold (coughing, sore throat, fever)?


Do you smoke? How much per day?


Do you frequently drink alcohol? How much per day?


Do you often take sleeping pills, tranquilizers or recreational drugs? Which?


Do you experience shortness of breath?


Do you have loose, chipped, false teeth, or bridgework?


Do you have any oral piercings, (such as studs or rings) in your tongue or lip?


Are you pregnant?


Have there been or are there any of the following conditions ?
YES No
Do you have a heart condition?


Have you experienced chest pain?


Do you have hypertension (high blood pressure)?


Do you have asthma, bronchitis, or any other breathing problem?


Do you have diabetes?


Do you have a thyroid condition?


Have you had hepatitis, liver disease, or jaundice?


Do you have or have you had kidney disease?


Do you have any muscle or nerve disease?


Do you have numbness, weakness, or paralysis of your extremities?


Do or did you ever suffer from a stroke?


Do you have bleeding problems?


Are you allergic (e.g. to latex (rubber) products, antibiotics, medication) ?


see reverse