| Questions |
| 1. Do you usually get chest pain or breathlessness when you climb up two flights of stairs at normal speed? |
| 2. Do you have kidney disease? |
| 3. Has anyone in your family (blood relatives) had a problem following an anaesthetic? |
| 4. Have you ever had a heart attack? |
| 5. Have you ever been diagnosed with an irregular heartbeat? |
| 6. Have you ever had a stroke? |
| 7. If you have been put to sleep for an operation were there any anaesthetic problems? |
| 8. Do you suffer from epilepsy or seizures? |
| 9. Do you have any problems with pain, stiffness or arthritis in your neck or jaw? |
| 10. Do you have thyroid disease? |
| 11. Do you suffer from angina? |
| 12. Do you have liver disease? |
| 13. Have you ever been diagnosed with heart failure? |
| 14. Do you suffer from asthma? |
| 15. Do you have diabetes that requires insulin? |
| 16. Do you have diabetes that requires tablets only? |
| 17. Do you suffer from bronchitis? |
