Date of the reaction Time of onset of reaction …./…./…….. …./….h (24h clock) Suspected cause of the reaction 1) ……………………….. 2) …………………..…… 3) ……………………..… Proposed surgical procedure:…………………………………….. Was surgery completed? Yes □ No □ for surgery being scheduled? Yes No If ‘no’, has another date □ □ Urgency of future surgery.……………………………………………………………... Details of the reaction Symptom/ Sign Onset Time Time resolved Severity (Mild/Moderate/Severe) (24 h clock) (24 h clock) Hypotension Lowest BP / mmHg Tachycardia Bradycardia Bronchospasm Cyanosis/ Lowest SpO2 desaturation Angioedema Urticaria Arrhythmia Flushing Itching Other (specify)
Date of the reaction …./…./…….. Time of onset of reaction …./….h (24h clock) Suspected cause of the reaction 1) ……………………….. 2) …………………..…… 3) ……………………..… Proposed surgical procedure:…………………………………….. Was surgery completed? Yes □ No □ If ‘no’, has another date for surgery being scheduled? Yes □ No □ Urgency of future surgery.……………………………………………………………... Details of the reaction Symptom/ Sign Onset Time (24 h clock) Time resolved (24 h clock) Severity (Mild/Moderate/Severe) Hypotension Lowest BP / mmHg Tachycardia Bradycardia Bronchospasm Cyanosis/ desaturation Lowest SpO2 Angioedema Urticaria Arrhythmia Flushing Itching Other (specify)
AAGBI%20referral%20form%20updated%20for%20NAP6%20Nov%2015.docx