questionario di autovalutazione dello stato di salute IN GRAVIDANZA

your state of HEALTH during YOUR PREGNANCY - QUestioNnaire

Fill in the form providing all your personal details

Mrs/Ms ______/ Age ______/ Weight before pregnancy ______kg / current ______kg / Height ______cm

Answer the questions, ticking the appropriate box YES, NO, DON’T KNOW

1.Do you have dentures? / Yes / no / don’t know
2.Do you have loose teeth? / yes / no / don’t know
3.Can you open your mouth fully? / yes / no / don’t know
4 Do you have neck stiffness or problems moving your head? / yes / no / don’t know
5 Do you have breathlessness while lying down; do you use more than one pillow in order to sleep better? / yes / no / don’t know
6Have you ever had an anaesthetic or surgery? / yes / no / don’t know
7 Have you ever had complications or problems after an anaesthetic? / yes / no
no / non so
don’t know
8 Have you ever received a blood transfusion? / yes / no / don’t know
9 Do you have or have you ever been treated for arthritis? / Yes / no / don’t know
10 Have you ever had heart or lung surgery? / Yes / no / don’t know
11 Have you ever had a pace-maker inserted? / Yes / no / don’t know
12 Have you ever had or been diagnosed as having cancer? / yes / no / don’t know
13 Do you have gastritis, hiatus hernia and/or stomach reflux? / yes / no / don’t know
14 Do you suffer from diabetes? / Yes / no / don’t know
15 Have you ever had kidney diseases? / Yes / no / don’t know
16 Do you suffer from migraines or headaches? / yes / no / don’t know
17 Do you have any allergies to medicines, food, plants, pollen, latex or rubber? / yes / no / don’t know
18 Have you ever had a blood clotting problem, are you susceptible to haematoma? / yes / no / don’t know
19 Have you ever had cardiac problems (arrhythmia or palpitations)? / yes / no / don’t know
20 Do you have high blood pressure? / yes / no / don’t know
21 Have you ever had chest pains, angina or chest heaviness? / yes / no / don’t know
22 Do you have mitral valve disease? / yes / no / don’t know
23 Have you ever had neurologic problems? / yes / no / don’t know
24 Have you ever had hepatitis, liver disease or malaria? / Yes / no / don’t know
25 Have you ever had difficulties breathing, asthma or pneumonia? / yes / no / don’t know
26 Have you ever had any pain while urinating or have you ever noticed blood in your urine? / yes / no / don’t know
27 Have you ever noticed bright red blood in faeces or on the toilet-paper? / Yes / no / don’t know
28 Have you ever vomited blood or something that resembles coffee dregs (residue at bottom of coffee cup)? / yes / no / don’t know
29 Have you ever had drinking abuse problems? / Yes / no / don’t know
30 Do you regularly smoke cigarettes, cigars or a pipe? How many a day? / Yes / no / don’t know
31 Have you taken narcotics in the last two years? / yes / no / don’t know
32 Have you taken any painkillers (analgesics) in the last week? / yes / no / don’t know
33 Are you taking or have you ever taken medicine for thyroid problems? / yes / no / don’t know
34 Have you taken antidepressants, sedatives or tranquilizers in the last 12 months? / yes / no / don’t know
35 Are you taking any alternative or herbal medicine? / yes / no / don’t know
36 Are you taking or have you taken cortisone in the last 12 months? / yes / no / don’t know
37 Are you taking any other types of medicine? / Yes / no / don’t know
38 If Yes, please list them ______
______
39 Have you had an ECG in the last two months? / yes / no / don’t know
40 Do you have blood circulation problems, varicose veins? / yes / no / don’t know
41 Do you have any spinal problems (herniated disc, scoliosis)? / yes / no / don’t know
42 Do you suffer from any other medical problems or sickness you think is important to tell us? / yes / no / don’t know
43 If Yes, please describe it/them to us______

QUESTIONS RELATING TO PREGNANCY HISTORY

1 Which week of your pregnancy are you in? ______

2 Have you had previous miscarriages? YES NO

3 Have you had previous pregnancies? YES NO

4 If yes, have you had any complications during your previous pregnancies?

5 please explain? ______

6 What have been the arrangements and methods for your previous delivery/deliveries? ______

7 Were you given an anaesthetic? Which were you given? Spinalepiduralgeneral

8 Did you have any complications with that anaesthesia? YES NO

9 Were you given an epidural during your previous deliveries? YES NO

10 If yes, were there any complications? YES NO

11 Is this pregnancy physiological? YES NO

12 Has a natural birth or a caesarean section been agreed upon prior to delivery? Natural birth Caesarean section

14 Expected date of birth? _____/_____/_____

NOTE: Before undergoing an analgesia epidural, you will be required to take coagulation tests (CBC )Blood count, prothrombin time (PT) – partial thromboplastin time (PTT).

We advise that your Doctor (GP) and Gynaecologist evaluate the possibility of suspension if any anti–platelet binding (eg aspirin) or anticoagulants (eg heparin) are being taken at least one week before the expected date of birth. The consumption of these drugs may counter-indicate an epidural (or any other forms of analgesia/anaesthetic local and topical).

INFORMED CONSENT FOR LABOUR ANALGESIA AND ANAESTHETIC FOR CAESAREAN SECTION

I ………………………………………...... declare to have been fully informed during the course of the informative meeting about the purposes and the ways of receiving analgesia during labour and delivery, and that I have received the pamphlet on the advantages, disadvantages, complications of these techniques by DR......
I ...... have understood that this procedure requires an administration of drugs through an epidural catheter (continuous epidural) or by a single injection directly into the liquid that surrounds the nerves of the spinal cord or a combination of these two techniques. I have understood that these techniques allow for pain relief during labour.

In particular I have been informed that the epidural (both spinal and combined) performed by expert anaesthetists is a safe procedure, well tested and efficient, but like all invasive medical procedures there can be advantages, side- effects, possible complications and counter-indications even when administered with skill, diligence and caution.

I can at any time request the interruption of the analgesia, if technically possible, without affecting my relationship with the doctors.

These anaesthetic techniques, where not counter-indicated, can also be used to perform a scheduled caesarean section or in the case of an emergency situation occurring during the labour that requires an unscheduled caesarean section.

Having read and understood the above description, I accept the necessary procedures and declare that I have received information and clear responses to all my questions.

Date ______Signature______

Sede legale: 30174 Venezia - Mestre - Via Don Federico Tosatto n.147 - tel. 041/2607111 - C.F. e P. IVA 02798850273 - cod. id. 050 – 112

C. F. e P. IVA 02798850273 - Casella postale 142 - cod. id. 050.112 – sito internet: - e-mail:

Comuni di Venezia - Cavallino Treporti - Marcon - Quarto d’Altino

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