Microsoft word - pre-op health questionnaire.doc

NORTHSIDE ANAESTHESIA
PRE-OPERATIVE ASSESSMENT QUESTIONNAIRE
Please complete and return as soon as possible. Circle appropriate answer.
Surname: ____________________________________
Given Names ___________________________________________ Address: ___________________________________________________________________________________Post code: _______ Phone: (H) (_____) _____________________ (W) (_____) ___________________ (Fax) (_____) _________________ Other contact details: ________________________________________________________________________________________ Proposed Operation or Procedure:______________________________________________________________________________
Operation Date: _______________________________ Admit Date: _________________________________
Surgeon’s Name: _______________________________ Hospital:_____________________________________

Who will be your next of kin, partner, parent, guardian or other responsible person for contact purposes?
Name: _______________________________________________ Phone: (H) (___) ________________ (W) (___) ______________ Do you have any language or other communication difficulties?
(Details: ________________________________________________________________________________________) What is your approximate weight: ___________ kgs and height: ___________ metres
PAST SURGICAL HISTORY
Have you ever had an operation before?
If “Yes” please give details _____________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ANAESTHETICS
Have you had any anaesthetics?
Have you had any problems or difficulties with anaesthetics?
Do you have blood relatives with anaesthetic problems? (details:_____________________________________________________________________________________________________ ___________________________________________________________________________________________________________ CARDIOVASCULAR SYSTEM
If “Yes” have you ever been hospitalised because of it? Details: _____________________________________________________________________________________________________ ___________________________________________________________________________________________________________ RESPIRATORY SYSTEM
(If so, have you ever been hospitalised because of it?) (Or have you ever required steroids (prednisone) to treat it?) Can you lie flat and level (with one pillow)? Can you walk up 12 stairs without stopping due to breathlessness? Yes No
Do you smoke or did you previously smoke?
No (If yes - how much______ how many_____) PATIENT SURNAME ______________________ GIVEN NAMES________________________
OTHER SYSTEMS
Heartburn, reflux or hiatus hernia? Yes
Diabetes (is it controlled by diet: tablets: insulin)?
Infectious diseases (hepatitis; HIV; AIDS etc.)?
Blood clots in the leg (DVT) or in the lung
Drugs to thin the blood (warfarin: aspirin etc.)? Is it possible that you are pregnant? n/a
(if yes – how much? __________________) Have you ever had a blood transfusion? Are there any other facts about your health or medical conditions that you believe I should know about in order to If “Yes” please give details _____________________________________________________________________________________ ___________________________________________________________________________________________________________ MEDICATIONS
Are you taking any medications?
(details_____________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ALLERGIES & ADVERSE REACTIONS
Have you any allergies or adverse reactions?
(details:_____________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ (e.g. Do you have problems with seafood, eggs, peanuts, iodine, sticky tapes, or x-ray dyes?) Any chipped or loose teeth?
Dentures, caps, bridges, crowns of any kind? Any jaw problems or trouble opening your mouth? (details:_____________________________________________________________________________________________________ ___________________________________________________________________________________________________________ RECENT INVESTIGATION
Have you recently had any tests?
Blood tests (Which Lab? S&N / QML / other ____________ ) Yes
Chest x-ray (where: ______________________________ ) Yes ECG, Echocardiograph, or Stress test (where :_____________ ) Lung function tests (where: ___________________________ ) Yes Who is your usual GP? ___________________________________________________Ph: (_____) __________________________
Do you mind if I contact them to discuss details of your medical history
Are there any other relevant details or requests you wish to add?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature of patient, parent or guardian: _________________________________ Date: ___________________
Return to
Northside Anaesthesia, Suite 20, Level 2 Holy Spirit Northside, 627 Road, Chermside 4032
or Fax to (07) 3359 7022

Source: http://www.northsideanaesthesia.com.au/documents/Pre-op%20Health%20Questionnaire.pdf