This survey has been formulated to help Mr Freedman’s anaesthetists and physicians assess your past medical history risk profile and to plan for your surgery. Please answer all questions truthfully and to the best of your ability. Your anaesthetist will review the information and may then contact you for further follow up or advise whether additional medical tests or assessment are required before your surgery.

Anaesthesia Screening Questionnaire

  • Patient Details

  • Patient Questionnaire

  • Allergies, Medication & Previous Operations

  • Please provide: What you're allergic to & Reaction.
  • Please provide: Drug, Dose & Frequency.
  • Please provide: Drug, Dose & Frequency.
  • Please provide: Condition/Operation & Date
  • This field is for validation purposes and should be left unchanged.