General Anaesthetic Questionnaire
First Name
*
Last Name
*
Location and Date of GA
*
Covid Vacinations:
*
No
Yes - one
Yes - two
Yes - three
Yes - four
Yes - See notes below
Previous Covid Infections:
*
No
Yes - Mild
Yes- Moderate
Yes - Severe
If yes, what date:
Height:
*
Weight:
*
Health Insurance deatails:
*
Name and Number
Message or Comment
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