Anaesthetic Pre-Procedure Form - Coastal Neurosurgery

Please complete our patient registration form before visiting to make your appointment as simple as possible.

Anaesthetic Pre-procedure Form

Given Name(s)

Surname

Height

in cm

Weight

in kgs

Have you ever had, or been told that you have had, any problems or difficulties during an anaesthetic procedure?

Please provide the date and name of hospital at which this occurred.

What medications do you take?

Please include any alternative or homeopathic therapies.

Cardiologist

Doctor's name, Practice name and last date you visited. Please type N/A or Not Visited if you have not seen.

Respiratory Physician

Doctor's name, Practice name and last date you visited. Please type N/A or Not Visited if you have not seen.

Endocrine/Diabetes Specialist

Doctor's name, Practice name and last date you visited. Please type N/A or Not Visited if you have not seen.

Pain Specialist

Doctor's name, Practice name and last date you visited. Please type N/A or Not Visited if you have not seen.

Haematologist

Doctor's name, Practice name and last date you visited. Please type N/A or Not Visited if you have not seen.

Vascular Surgeon

Doctor's name, Practice name and last date you visited. Please type N/A or Not Visited if you have not seen.

Neurologist

Doctor's name, Practice name and last date you visited. Please type N/A or Not Visited if you have not seen.

Do you have any allergies?

Please detail the reaction that occurred.

What medical conditions do you have that your GP manages?

Eg. High blood pressure, asthma, diabetes, polymyalgia, blood clots, irregular heart beat

Have you had any hospital admissions or major investigations in that last 12 months?

Do you smoke?

Yes

No

How many cigarettes/ vapes per day?

Do you drink alcohol?

Yes

No

How many standard drinks per day?

If you are human, leave this field blank.

Expert Neurosurgical and Spinal Surgical Care on the Central Coast

Coastal Neurosurgery is a multidisciplinary clinic with a dedicated focus on brain, spine and pain.