Only note here medication you take daily or regularly Also note here products you get from the pharmacist or else without prescription: painkillers, stomach acid inhibitors, sleeping medicine, vitamins, food supplements, syrups, eye drops… □ I don’t take medication I take daily: FULL name drug + strength + shape How much of the drug do you take? Remarks: + (tablet, drops, syrup…) ex. sober, every 2 when in the day? days, 1x /week, 1x Tip: Check the packaging + bring along all /month, if packaging to the hospital! necessary, etc morning noon before evening sleeping Ex. Lasix 40 mg tablet 1 (8u) 0,5 (12u) The following medication I don’t take daily: Ex. Fosamax 70 mg tablet 1 (7u) Sober 1 x /week Do you wish to mention something else? □ yes □ no ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… Where can we reach a family member or someone else? Cell phone number:……………………………………………………….
Only note here medication you take daily or regularly Also note here products you get from the pharmacist or else without prescription: painkillers, stomach acid inhibitors, sleeping medicine, vitamins, food supplements, syrups, eye drops… □ I don’t take medication I take daily: FULL name drug + strength + shape (tablet, drops, syrup…) How much of the drug do you take? + when in the day? Remarks: ex. sober, every 2 days, 1x /week, 1x /month, if necessary, etc Tip: Check the packaging + bring along all packaging to the hospital! morning noon evening before sleeping Ex. Lasix 40 mg tablet 1 (8u) 0,5 (12u) The following medication I don’t take daily: Ex. Fosamax 70 mg tablet 1 (7u) Sober 1 x /week Do you wish to mention something else? □ yes □ no ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… Where can we reach a family member or someone else? Cell phone number:……………………………………………………….
preoperatieve_vragenlijst_in_engels.docx