JADUZAR INK / ANESTHESIA

MEDICAL QUESTIONNAIRE FOR TREATMENT UNDER ANESTHESIA

Complete this questionnaire fully and truthfully for your JADUZAR INK treatment involving a medical or anesthesia service. Your information is first reviewed by JADUZAR INK and may then be forwarded to the responsible medical professional for assessment. Submitting this form does not mean that you have been medically approved.

  • One questionnaire per order, not one per service.
  • For adults aged 18 and over only.
  • All required questions must be completed.
  • The responsible medical professional makes the final medical decision.

Part 1 of 7

Personal details

Questions 1 to 10.

You will find this at the top of your JADUZAR INK order confirmation e-mail. If you have not ordered yet, write “no order yet”.

Sex / Gender*

Part 2 of 7

Procedure and general medical information

Questions 11 to 17.

Fixed for this form

Do you take any medication? Please also consider contraceptives.*

Do you drink alcohol?*

Do you smoke?*

Do you use recreational drugs?*

Do you have any allergies?*

Have you had surgery before?*

Part 3 of 7

Symptoms and medical conditions — part 1

Questions 18 to 32.

Have you ever had a heart attack?*

Do you have chest pain?*

Do you take blood thinners?*

Do you experience shortness of breath during physical exertion?*

Do you use inhalers or lung medication?*

Do you have palpitations or a heart rhythm disorder?*

Do you have a pacemaker or ICD?*

Do you have high blood pressure?*

Do you have narrowing of the blood vessels?*

Do you have wheezing or whistling breathing sounds?*

Do you have coughing, phlegm, or pain when breathing?*

Do you have symptoms consistent with asthma or COPD?*

Do you have muscle weakness?*

Do you have seizures, blackouts, or epilepsy?*

Part 4 of 7

Symptoms and medical conditions — part 2

Questions 33 to 45.

Do you experience nervousness, anxiety, or depression?*

Do you have any known bowel diseases?*

Do you have conditions affecting the urinary tract and/or kidneys?*

Do you have any endocrine/hormonal disorders?*

Do you have diabetes?*

Do you have a thyroid disorder?*

Have you recently been ill or had an accident?*

Have you recently been admitted to or treated in a hospital abroad?*

Have you recently been in contact with MRSA or do you work with livestock?*

Are you able to climb two flights of stairs, vacuum a carpet, mow the lawn with a non-electric mower, or cycle at 15 km/h?*

Can you open your mouth wide?*

Do you have any loose teeth?*

Do you have a nose piercing?*

Part 5 of 7

Contact details and declaration

Questions 46 to 49.

I declare that I have completed this medical questionnaire fully and truthfully.*

Important medical notice

The information in this form does not replace a medical examination. Whether anesthesia or sedation is medically appropriate is determined only by the responsible medical professionals.

Part 6 of 7

Consent and permissions

These choices are separate from the medical questions above.

MEDIA CONSENT — SEPARATE FROM MEDICAL SCREENING

Your media choice does not affect your booking, your treatment or the medical review.

You can withdraw your media consent at any time by writing to info@jaduzar.com.

PROCESSING AND FORWARDING CONSENT

PRIVACY ACKNOWLEDGEMENT

How your information is handled

JADUZAR INK collects the health information in this questionnaire only to assess whether a treatment under anesthesia is possible. It is sent by e-mail to info@jaduzar.com, reviewed by JADUZAR INK, and may then be forwarded to the responsible doctor for medical assessment. E-mail is not a secure medical portal and is not end-to-end encrypted. Your media choice is used for a separate purpose and never affects the medical review. To withdraw consent, or to request access, correction or deletion of your information, write to info@jaduzar.com.

Part 7 of 7

Review and send

Check your answers before sending. Use Back to correct anything.

Your reference — please note it down —

Sending this questionnaire submits it to JADUZAR INK for internal review. It is not a booking and it is not medical approval. The responsible doctor makes the final medical decision.

JavaScript is switched off, so all 49 questions are shown on this single page. Complete them and press Send — your questionnaire reaches JADUZAR INK in exactly the same way.