blood pressure:		according to age		compensated
			arterial hypertension		decompensated
	heart / lung:		normal function		light		severe
			cardiac insufficiency		light		severe
			dyspnoea		light		severe
			rhythm disturbances		light cardiac dysrhythmia
					absolute arrhythmia
					pacemaker
	diabetes:		no diabetes
			insulin type		diet
			................................ i.u.		tablets
					blood-sugar adjustment:		good
							poor
	coagulation:		normal		cumarine – quick test/PTT on ......................... = .......%
			delayed
			increased		heparin – dose .......................................... i. u.
	liver:		normal		s.p. hepatitis B / C		alcoholism
	drug allergy:		not known
			known against ......................................................................
	other findings:
	The operability of the patient ................................................................................................................................ for a surgery under
			general anaesthesia		local anaesthesia
			is thought by me given		with the following reservation:
			without reservation		................................................................................
			is thought by me not given		................................................................................
					................................................................................ date / stamp / signature