Ankieta anestezjologiczna w j. angielskim | Anesthesiology questionnaire in English





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WHAT ARE THE RISKS OF ANESTHESIA? (please read the information below)


Modern methods of anaesthesia are generally very safe. However, every type of anaesthesia carries the risk of side effects and complications. Although they are usually short-lived and temporary, some can cause long-term problems. The side effects and complications presented belowa re not an exhaustive list.

Common side effects and complications include: for all types of anaesthesia:

• nnausea (feeling sick) and vomiting affect approximately 35% of patients undergoing anaesthesia

• dizziness and feeling weak

• chills

• headache

• itching

• pain during the administration of medications

• bruising and soreness around the places where injections and drips were administered

• bladder problems/problems urinating

• respiratory infections

in case of general anaesthesia and/or sedation:

• confusion (delirium) / behavioural disturbances

• emotional stress

• memory loss: this is more common among older people

• sore throat

• vision disorders

• somnolence

• damage to teeth, lips and tongue

in case of regional / local anaesthesia:

• long-lasting numbness or tingling

• lowering blood pressure.

Uncommon side effects and complications include:

for all types of anaesthesia:

• worsening of existing health problems

• allergic reactions

• breathing problems

• the anaesthetic does not fully work (e.g. return of consciousness during general anaesthesia or the need to general anaesthesia when regional anaesthesia does not fully block sensation/pain in the area of the body subjected to regional anaesthesia)

in case of general anaesthesia and/or sedation:

• eye damage (e.g. abrasions on the front of the eye), these lesions usually heal easily

• muscle pain

• sleep disorders

in case of general / regional / local anaesthesia:

• nerve damage (paralysis or numbness): their scope and location depend on the type of anaesthesia that was performer and most often these are transient changes, but in some cases there may be permanent consequences
in case of regional anaesthesia

• toxic effects of local anaesthetics (sre treated as they occur)

• severe headache.

Rare side effects and complications include:

for all type of anaesthesia:

• serious allergic reaction

• gastric contents entering the lungs and damaging them

• equipment failure, including needle breakage during the anaesthesia procedure

• cardiac arrest

• stroke

• permanent disability (e.g. permanent nerve damage with possible paralysis or paresis)

• deafness (usually short-lived)

• serious breathing problems (very rare)

• convulsions (very rare)

• severe damage or death (very rare)

in case of general anaesthesia and / or sedation

• vision loss and blindness

• rapid and significant increase in body temperature

in case of regional anaesthesia:

• infection (e.g. around injection site and epidural catheter; meningitis; epidural abscess

Specific side effects and complications

There may also be risks specific to your individual condition and circumstances. The risk in a specific, individual case will depend on:

• how simple or complex the operation is,

• how long the surgery takes,

• whether the surgery is emergency, urgent or planned.

The risk of anaesthesia i salso increased by:

• old age

• smoking

• overweight and obesity

• and the presence of additional factors:

– cold or flu, asthma or other respiratory disease

– diabetes

– heart disease

– kidney disease

– high blood pressure

– and / or other serious medical conditions.


Please complete the questionnaire which is intended to help the anaesthesiologist prepare you for surgery and then safely perform anaesthesia. Please answer the questions according to your knowledge. Any doubts will be discussed during the preoperative aesthetic consultation. An anesthesiologist is a specialist who assesses the patient’s health conditio before the planned surgery, orders consultations with other specialists if necessary, and then selects and discusses the type of anaesthesia appropriate to the patient’s health conditio and the planned type of surgery, assesses the risk associated with anaesthesia, plans and presents the course of the anaesthesia and postoperative pain treatment, is responsible for conducting anaesthesia, provides care during surgery and in the immediate postoperative period. The preoperative questionnaire is used to collect information on the basis of which it will be possible to select the most favorable anesthetic procedure. Your cooperation will contribute to the optimal course of anesthesia. Please answer these questions very carefully. Please raise any ambiguities during the conversation with the anesthesiologist and sign the consent to anesthesia in his presence.


(please express the measurement in kg)
(please express measurement in cm)
(please specify)
Please list the names of the drugs along with the dosage and information on how long the drug has been taken (e.g. Ketonal 100mg twice a day in the morning and evening)
List the important factors.
Please list and provide dates of procedures (e.g. appendix removal – December 1990)
If YES, please list the type of complications or describe them in your own words. If there have been NO complications or close relatives have NOT had surgery, please proceed to the next question.
Please tick.
Before the procedure, there will be an anesthesiological consultation, during which you will be able to personally talk to the doctor and sign a consent to anesthesia in his presence. You will be informed about the date of the consultation by the Hospital Care Coordinators.

    If you have any questions, you are at your disposal:

  • Agnieszka Sobel – 530 838 087
  • Monika Kramarczyk tel. 603 763 336
  • Ewelina Paciorkowska tel. 668 600 805
  • Elżbieta Zimmermann tel. 661 760 329