{"id":883,"date":"2017-07-10T13:47:35","date_gmt":"2017-07-10T12:47:35","guid":{"rendered":"https:\/\/www.ddg-gastro.be\/?page_id=883&#038;lang=en"},"modified":"2021-01-21T15:49:02","modified_gmt":"2021-01-21T14:49:02","slug":"anesthesia-form","status":"publish","type":"page","link":"https:\/\/welliecare.com\/en\/anesthesia-form\/","title":{"rendered":"Anesthesia Form"},"content":{"rendered":"\n<h1 class=\"wp-block-heading\">Anesthesia questionnaire<\/h1>\n\n\n\n<h2 class=\"wp-block-heading\">What is its use?<\/h2>\n\n\n\n<p>This questionnaire allows you to assess your state of health before digestive endoscopy. It is part of the preoperative assessment and is strictly confidential. By affixing your signature on this form, you also give the authorization for the anesthesia. You can complete the document yourself or have it completed by a representative. <strong><a href=\"https:\/\/welliecare.com\/en\/consultations\/anesthesiology\/\">More information about anesthesia<\/a><\/strong>.<\/p>\n\n\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f884-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"884\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/883#wpcf7-f884-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"884\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.4\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f884-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"column one check\">\n\t<h2>Questionnaire:\n\t<\/h2>\n<\/div>\n<div class=\"column one check\">\n\t<h3>Informations\n\t<\/h3>\n<\/div>\n<div class=\"column one-third\">\n\t<p><label>Name:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one-third\">\n\t<p><label>First name:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"your-lastname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-lastname\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one-third\">\n\t<p><label>Adress:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"your-adress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-adress\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one-third\" style=\"margin-bottom:5px;\">\n\t<p><label>Birth date:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"Datedenaissance\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"dd-mm-yyyy\" type=\"date\" name=\"Datedenaissance\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one-third\">\n\t<p><label>Height:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"Taille\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"Taille\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one-third\">\n\t<p><label>Weight:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"Poids\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"Poids\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one-third\" style=\"margin-top:25px;\">\n\t<p><label>Doctor:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"medecin-traitant\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medecin-traitant\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one-third\" style=\"margin-top:25px;\">\n\t<p><label>Phone:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-phone\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one-third\" style=\"margin-top:25px;\">\n\t<p><label>Mail:<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-email\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one check\">\n\t<h3>Scheduled Anesthesia Technique: Light General Anesthesia\n\t<\/h3>\n<\/div>\n<div class=\"column one\">\n\t<p>Living alone <span class=\"wpcf7-form-control-wrap\" data-name=\"Habiteseul\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"Habiteseul[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"Habiteseul[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Back home accompanied <span class=\"wpcf7-form-control-wrap\" data-name=\"retouraccompagne\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"retouraccompagne[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"retouraccompagne[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one check\" style=\"margin-bottom:15px; margin-top:15px\">\n\t<h4>Medical History :\n\t<\/h4>\n<\/div>\n<div class=\"column two-fifth\">\n\t<p>Have you had surgery? <span class=\"wpcf7-form-control-wrap\" data-name=\"interventions\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"interventions[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"interventions[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column three-fifth\">\n\t<p>If so, which and when? :<span class=\"wpcf7-form-control-wrap\" data-name=\"vos-interventions\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"vos-interventions\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column two-fifth\">\n\t<p>Did you have any anesthetic or surgical problems?:<span class=\"wpcf7-form-control-wrap\" data-name=\"presence-problemes\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"presence-problemes[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"presence-problemes[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column three-fifth\">\n\t<p>If so why ? :<span class=\"wpcf7-form-control-wrap\" data-name=\"vos-presences\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"vos-presences\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column two-fifth\">\n\t<p>Do you take medications regularly ?<span class=\"wpcf7-form-control-wrap\" data-name=\"prise-medicaments\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"prise-medicaments[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"prise-medicaments[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column three-fifth\">\n\t<p>If so, which ones ? (Name, frequency and dose) :<span class=\"wpcf7-form-control-wrap\" data-name=\"vos-medicaments\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"vos-medicaments\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column two-fifth\">\n\t<p>Do you smoke ?<span class=\"wpcf7-form-control-wrap\" data-name=\"fumer\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"fumer[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"fumer[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column three-fifth\">\n\t<p>If so, how many cigarettes a day ? :<span class=\"wpcf7-form-control-wrap\" data-name=\"cigarettes\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cigarettes\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column two-fifth\">\n\t<p>Are you drinking regularly or occasionally alcohol ?<span class=\"wpcf7-form-control-wrap\" data-name=\"alcool\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"alcool[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"alcool[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column three-fifth\">\n\t<p>If so, how much and how often? :<span class=\"wpcf7-form-control-wrap\" data-name=\"frequence-alcool\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"frequence-alcool\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column two-fifth\">\n\t<p>Do you have allergic reactions ?<span class=\"wpcf7-form-control-wrap\" data-name=\"reaction-allergique\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"reaction-allergique[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"reaction-allergique[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column three-fifth\">\n\t<p>If so, which ones? :<span class=\"wpcf7-form-control-wrap\" data-name=\"type-reaction\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"type-reaction\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one check\" style=\"margin-bottom:15px; margin-top:15px\">\n\t<h4>Do you have :\n\t<\/h4>\n<\/div>\n<div class=\"column one\">\n\t<p>Removable dental prostheses ?<span class=\"wpcf7-form-control-wrap\" data-name=\"protaises-amovibles\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"protaises-amovibles[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"protaises-amovibles[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Fixed dental prostheses <span class=\"wpcf7-form-control-wrap\" data-name=\"protaises-fixes\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"protaises-fixes[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"protaises-fixes[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Of loosened teeth ?<span class=\"wpcf7-form-control-wrap\" data-name=\"dents-dechaussees\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"dents-dechaussees[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"dents-dechaussees[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Do you wear contact lenses ?<span class=\"wpcf7-form-control-wrap\" data-name=\"lentilles\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"lentilles[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"lentilles[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one check\" style=\"margin-bottom:15px; margin-top:15px\">\n\t<h4>For women :\n\t<\/h4>\n<\/div>\n<div class=\"column two-fifth\">\n\t<p>Do you think you're pregnant ? <span class=\"wpcf7-form-control-wrap\" data-name=\"enceinte\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"enceinte[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"enceinte[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column three-fifth\">\n\t<p>If so, how many weeks ? :<span class=\"wpcf7-form-control-wrap\" data-name=\"duree-enceinte\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"duree-enceinte\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Are you taking the pill ?<span class=\"wpcf7-form-control-wrap\" data-name=\"pilule\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"pilule[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"pilule[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one check\" style=\"margin-bottom:15px; margin-top:15px\">\n\t<h4>Bleeding And Transfusion:\n\t<\/h4>\n<\/div>\n<div class=\"column one\">\n\t<p>Do you take aspirin, sintrom, plavix or other anticoagulant medication ?<span class=\"wpcf7-form-control-wrap\" data-name=\"anticoagulants\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"anticoagulants[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"anticoagulants[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Do you get easily a bruise or do you bleed easily from the nose ?<span class=\"wpcf7-form-control-wrap\" data-name=\"nez\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"nez[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"nez[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Do you have known coagulation problems in your family ?<span class=\"wpcf7-form-control-wrap\" data-name=\"coagulation\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"coagulation[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"coagulation[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column two-fifth\">\n\t<p>Have you ever received a blood transfusion ?<span class=\"wpcf7-form-control-wrap\" data-name=\"transfusion-sanguine\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"transfusion-sanguine[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"transfusion-sanguine[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column three-fifth\">\n\t<p>If so, why and when ? :<span class=\"wpcf7-form-control-wrap\" data-name=\"raison-transfusion\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"raison-transfusion\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one check\" style=\"margin-bottom:15px; margin-top:15px\">\n\t<h4>Diseases :\n\t<\/h4>\n<\/div>\n<div class=\"column one\" style=\"margin-bottom:15px; margin-top:15px\">\n\t<p>Do you suffer or did you suffer: :\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Of Heart disease ?<span class=\"wpcf7-form-control-wrap\" data-name=\"maladie-coeur\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"maladie-coeur[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"maladie-coeur[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Of Blood pressure too high ?<span class=\"wpcf7-form-control-wrap\" data-name=\"tension-arterielle\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"tension-arterielle[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"tension-arterielle[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Of diabetes ?<span class=\"wpcf7-form-control-wrap\" data-name=\"diabete\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"diabete[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"diabete[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Of asthma ?<span class=\"wpcf7-form-control-wrap\" data-name=\"ashme\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"ashme[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"ashme[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Of hepatitis or other liver disease ?<span class=\"wpcf7-form-control-wrap\" data-name=\"maladie-foie\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"maladie-foie[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"maladie-foie[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Of a gastric ulcer, gastritis ? <span class=\"wpcf7-form-control-wrap\" data-name=\"ulcere-gastrique\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"ulcere-gastrique[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"ulcere-gastrique[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Of a Thyroid Disease ?<span class=\"wpcf7-form-control-wrap\" data-name=\"thyroide\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"thyroide[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"thyroide[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Of Eye disease ?<span class=\"wpcf7-form-control-wrap\" data-name=\"yeux\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"yeux[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"yeux[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>From a transmissible disease ?<span class=\"wpcf7-form-control-wrap\" data-name=\"maladie-transmissible\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"maladie-transmissible[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"maladie-transmissible[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column two-fifth\">\n\t<p>Another disease ? <span class=\"wpcf7-form-control-wrap\" data-name=\"autre-maladie\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"autre-maladie[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"autre-maladie[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column three-fifth\">\n\t<p>If so which one ? :<span class=\"wpcf7-form-control-wrap\" data-name=\"quelle-maladie\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"quelle-maladie\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one check\" style=\"margin-bottom:15px; margin-top:15px\">\n\t<h4>Cardiorespiratory function :\n\t<\/h4>\n<\/div>\n<div class=\"column one\">\n\t<p>Are you out of breath by going one level upstairs on foot ?<span class=\"wpcf7-form-control-wrap\" data-name=\"essoufflement\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"essoufflement[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"essoufflement[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Do you suffer from pain in the chest (angina pectoris) during exercise, nervousness, after the meal or because of cold ?<span class=\"wpcf7-form-control-wrap\" data-name=\"poitrine\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"poitrine[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"poitrine[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Should you sleep with your head raised so as not to be out of breath ?<span class=\"wpcf7-form-control-wrap\" data-name=\"tete-surrelevee\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"tete-surrelevee[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"tete-surrelevee[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Do you suffer from palpitations ?<span class=\"wpcf7-form-control-wrap\" data-name=\"palpitations\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"palpitations[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"palpitations[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Do you wear a pacemaker ?<span class=\"wpcf7-form-control-wrap\" data-name=\"pacemaker\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"pacemaker[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"pacemaker[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p>Do you wear an artificial valve ?<span class=\"wpcf7-form-control-wrap\" data-name=\"valve-artificielle\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"valve-artificielle[]\" value=\"yes\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"valve-artificielle[]\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"column one\" style=\"margin-bottom:15px; margin-top:15px\">\n\t<p>If you are taking medication, your treatment should be continued on the day of your examination unless the anesthesiologist advises differently. In some cases, temporary discontinuation of certain medications will be required a few days before the exam (eg Plavix, Cardioaspirin, Asaflow and Sintrom as well as some antihypertensive and antidepressants).<br \/>\n<b>It is also essential to remove the nail polish and any piercings.<\/b>\n\t<\/p>\n\t<p><b>A document relative to free and informed consent must be completed and signed for the day of the examination.<a href=\"\/wp-content\/uploads\/2016\/10\/consentement-1.pdf\" target=\"_blank\">Obtain the document<\/a>.<\/b>\n\t<\/p>\n<\/div>\n<div class=\"column one\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-595\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"acceptance-595\" value=\"1\" aria-invalid=\"false\" \/><\/span><\/span><\/span>I hereby declare that all the information given above is true.\n\t<\/p>\n<\/div>\n<div class=\"column one\" style=\"margin-bottom:15px; margin-top:15px\">\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n\t<\/p>\n<\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"9\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Anesthesia questionnaire What is its use? This questionnaire allows you to assess your state of health before digestive endoscopy. It is part of the preoperative assessment and is strictly confidential.<span class=\"excerpt-hellip\"> [\u2026]<\/span><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-883","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Anesthesia form for quality examinations at the DDG center<\/title>\n<meta name=\"description\" content=\"Complete the Online anesthesia questionnaire to assess your health and ensure the good quality of the examinations in our center.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/welliecare.com\/en\/anesthesia-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" 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