Pre-Operative Anesthesia Questionnaire
Digital pre-anesthesia screening questionnaire for Swiss hospitals and surgical centres. Collect medication history, allergies, prior anesthesia reactions, and fasting status securely under Swiss KVG and nFADP health data regulations.
About this template
The Pre-Operative Anesthesia Questionnaire is designed for Swiss hospitals, day surgery centres, and outpatient surgical clinics. It collects the clinical information required for the anaesthesiologist's pre-operative assessment, enabling the anaesthesia team to identify risk factors, plan the appropriate anaesthetic technique, and ensure patient safety on the day of surgery.
Important: Answer all questions accurately
Incomplete or inaccurate answers to pre-anesthesia questions can pose serious risks to patient safety. If you are unsure about any answer, please consult your general practitioner or the surgical team before submitting. This form does not replace the in-person pre-anesthesia consultation.
What this form collects
- Patient identification and contact details
- Planned surgical procedure and scheduled date
- Current medications (including blood thinners, supplements)
- Known allergies and adverse drug reactions
- Prior anaesthesia history and any complications
- Relevant medical history (cardiac, respiratory, neurological, metabolic)
- Smoking, alcohol, and substance use history
- Fasting status acknowledgment
- Patient signature for informed consent to anaesthesia data processing
How to use this template
Use this template
Click 'Use template' to create a copy in your dashboard.
Set the surgical procedure field
Pre-fill or lock the surgical procedure field if this form is procedure-specific (e.g. knee arthroscopy).
Send pre-appointment
Send the form link to patients 48-72 hours before the pre-op consultation or surgery date.
Review flagged responses
The anaesthesiologist reviews submitted forms and flags any high-risk responses before the consultation.
Integrate with patient records
Export completed forms to your hospital information system (HIS) or clinical documentation platform.
Pre-Operative Anesthesia Assessment in Swiss Hospitals
In Switzerland, pre-anaesthesia assessment is a standard requirement for all elective surgeries and most urgent procedures. The assessment is conducted by an anaesthesiologist or a trained anaesthesia nurse under physician supervision. Its primary goal is to stratify the patient's anaesthetic risk using the ASA Physical Status Classification, identify contraindications to specific agents, and discuss the planned anaesthetic technique with the patient.
What is the ASA classification?
The American Society of Anesthesiologists (ASA) classification system assigns patients a score from I (healthy patient) to VI (brain-dead organ donor). Swiss hospitals use the ASA score to guide anaesthetic planning and determine the appropriate care setting (day surgery vs. inpatient). Most day surgery patients are ASA I or II. ASA III patients with controlled systemic disease may be managed in day surgery with additional monitoring protocols.
What medications affect anaesthesia?
Several medication classes require special attention before anaesthesia. Anticoagulants and antiplatelet drugs must typically be paused before surgery to reduce bleeding risk. ACE inhibitors and ARBs may cause intraoperative hypotension. Insulin and oral hypoglycaemics require adjustment for the fasting period. Monoamine oxidase inhibitors (MAOIs) interact dangerously with several anaesthetic agents. Herbal supplements can affect bleeding and drug metabolism. Patients must disclose all medications, including over-the-counter drugs and supplements.
What are the fasting (NPO) requirements in Switzerland?
Swiss anaesthetic guidelines align with European Society of Anaesthesiology (ESA) recommendations: patients should fast from solid food and milk for at least 6 hours before anaesthesia, and from clear fluids for at least 2 hours. Chewing gum, sweets, and alcohol are prohibited for at least 6 hours. Non-compliance with fasting rules may result in postponement of surgery due to aspiration risk.
What is malignant hyperthermia and why does it matter?
Malignant hyperthermia (MH) is a rare, potentially fatal pharmacogenetic disorder triggered by volatile anaesthetic agents and succinylcholine. It causes rapid, uncontrolled skeletal muscle metabolism resulting in hyperthermia, acidosis, and rhabdomyolysis. Patients with a personal or family history of MH must receive a totally intravenous anaesthetic (TIVA) technique. Disclosure of family history of anaesthesia complications is therefore a critical component of the pre-anaesthesia questionnaire.
Legal and data protection framework in Switzerland
Pre-operative health questionnaires collect GDPR Article 9 and nFADP category health data (sensitive personal data). In Switzerland, this processing is permitted for the provision of healthcare under KVG. Hospitals must inform patients of the data controller identity, the purpose of processing, and retention periods (minimum 10 years for clinical records under cantonal health legislation). Schweizerform ensures that digital form data is stored exclusively in Switzerland with AES-256 encryption.
Frequently asked questions
When should I complete the pre-anesthesia questionnaire?
Ideally 24-72 hours before your scheduled pre-operative consultation or surgery date. This gives the anaesthesia team time to review your responses and contact you if clarification is needed, potentially avoiding last-minute delays on the day of surgery.
What if my medications change after I submit the form?
Inform the surgical team immediately if your medications change between submitting the form and the day of surgery. Any new prescription, over-the-counter drug, or supplement started after submission must be disclosed, as it may affect the anaesthetic plan.