All India Institute of Medical Sciences (AIIMS) Jodhpur

Department of Anaesthesiology
fu'psruk (GENERAL ANAESTHESIA) के िलए सू िचत सहमित
eSsa GENERAL ANAESTHESIA ds fy, esjh lgefr nsrk gwa] ftlds ladsr] ykHk vkSj gkfu eq>s vPNh rjg ls le>k, x, gSA
eSa Åij dh xbZ izfØ;k ls tqMs laHkkfor ifj.kkeksa vkSj tksf[ke dks le>rk gwa tks fd uhps nh xbZ lwph rd lhfer ugha gSaA

iksLVvkWijsfVo eryh vkSj mYVh nnZ ¼tSls fljnnZ] ihB nnZ½

xys esa [kjkl {kf.kd Hkze ;k Le`fr gkfu
pDdj vkuk vkSj csgks”k eglwl djuk Ekw= dk ikj djus esa dfBukbZ lkWl ysus esa dfBukb] lhus esa laØe.k
daIkdfi nkar] gksaB vkSj thHk dks uqdlku
[kqtyh vos;juSl
vkW[kksa dks uqdlku ul dh {kfr
ekStwnk fpfdRlk dh fLFkfr cnrj gks ldrh gSa A ;kaf=d osafVys”ku dh vko”;drk dks ldrh gSA
dkfMZ;d dh tfVyrk,a tSls ek;ksdkfMZ;y nokvksa ls xaHkhj ,ythZ ls ¼,ukfQysfDll½
bLkfdfe;k@bUÝkD”ku] vkfjZFkfe;kl
jh< dh gMMh esa ulksa dks lFkk;h {kfr midj.k dh vlQyrk
e`R;q <1

eSa] fdlh vU; izfØ;k@izfØ;k esa cnyko @vkbZlh;w HkrhZ dh vko”;drk ds fy, Hkh esjh lgefr nsrk gaW]w tSlk fd mipkj ds
nkSjku vko”;d le>k tkrk gSA
eSa vko”;d nok,W nsus] vko”;drk iMus ij jDr@jDr mRiknksa dks p<kus ds fy, viuh lgefr nsrk gWwA
eSa fdlh Hkh Kkr ,ythZ ;k u”khyh nokvksa dh izfrfØ;kvksa ls ihfM+r ugha gwa @gwa ----------------------------------------------- nok dk uke@,ythZ
eSa mPp jDrpki@e/kqesg@Fkk;jkW;M jksx@lkal dh chekjh@ân; jksx ;k ----------------- fdlh Hkh vU; izeq[k chekjh ls ihfMr
gwa@ihfMr ugha gwa@bykt dj jgk gwa@bykt ij ugha gaw -------------------------------------------------------------------------------------------------- mipkj dk fooj.k
eSa ------------------------------------------------------------------------------------------------------------------------ ds fy, esjh lgefr ugha nsrkA ¼izfØ;k dk uke½@ykxw ugha

ejht@fj'rsnkj }kjk fdlh Hkh iz”u ij ppkZ%

xokg 1 gLrk{kj ¼uke½ jksxh@ fj'rsnkj ds gLrk{kj ¼uke½

xokg 2 gLrk{kj ¼uke½

fnukad vkSj le;%
 All India Institute of Medical Sciences (AIIMS) Jodhpur
Department of Anaesthesiology
Informed Consent for GENERAL ANAESTHESIA
I give my consent for General Anaesthesia, the indications, benefits and risk of which have been well explained
to me.
I understand the possible consequences and risks associated with above said procedure which include but are
not limited to the list given below:
Postoperative nausea and vomiting Transient Confusion or memory loss
Sore throat Difficulty passing urine
Dizziness and feeling faint Breathing difficulty, chest infection
Shivering Damage to teeth, lips and tongue
Itching Awareness
Aches (like headache, backache) and pain when drugs Damage to the eyes
are injected Nerve damage
Equipment failure Existing medical conditions getting worse
Cardiac complications like myocardiac Respiratory failure requiring mechanical
ischaemia/infarction, arrythmias ventilation
Permanent Damage to nerves in the spine Serious allergy to drugs (Anaphylaxis)
Death(<1%)
I also give my consent for any other procedure/ change of plan / requirement of ICU care post operatively as
deemed necessary during the course of treatment
I further give my consent for the administration of required drugs, infusions, blood/blood products, any other
treatment/procedure deemed necessary.
I state that I am suffering/ not suffering from any known allergy or drug
reactions…………………………………………………………………………….………. (Name of drug / allergen applicable)
I also state that I am suffering/ Not suffering from hypertension/ diabetes/ thyroid disease/ respiratory illness/
heart disease or ………………… (any other major illness) and I am on treatment / not on treatment
……………………………………………………………………………………………………………………….…..(Details of treatment)
I do not give my consent for ………………………………………………………. (Name of procedure)/ Not applicable.
Discussion on any query by patient/relative:

Witness 1: Signature/Name Signature/Name of patient/relative

Witness 2: Signature/Name Date & Time: