Examples of Premium Pre-Op Questionnaire Changes

Premium Plan members can change their pre-op health questionnaire as often as they like. We offer unlimited levels of depth to questions (responsive based on previous answers). We also allow complex questions, triggers, confirmations and notifications. Plus Premium Plan members receive unlimited changes, all included in their flat monthly subscription.

Premium Plan members can tailor the questionnaire to their exact requirements. There’s very little we can’t update for you – we want to make sure you are really getting the most out of this plan and completely happy with every question, improving your efficiency.

Below are some of the 100+ excellent changes our amazing members have made.

We have asked members if we can acknowledge them before listing their names below. If you change your mind and would now like your name listed next to your great idea, please feel free to contact us at any time. We love to give credit to great ideas.

What Premium members can change

When a new member signs up, they will be given the Standard Pre-Op Questionnaire (demo here). However, Premium members can change this questionnaire as often as they like.

There are endless options for your customisations and so, all changes to your forms and questionnaire will be free for the lifetime of your Premium Plan. Because we manually change the form for you, you can continually tweak it until it’s just right.

  • You can add or remove questions, according to their relevance
  • You can also create conditional questions, based on the details input by your patient (with an unlimited depth)
  • In addition, you can customise confirmation messages sent to your patients, yourself, and your office (For example: If the patient requests a quote, we can show them a quote based on the procedure / surgeon entered or even simply email their basic (non-medical) details to your billing secretary to reply)
  • You can opt to update the form or questionnaire styling. This could be the inclusion or removal of page breaks, or specific text, buttons, and displayed messages
  • You can create special conditional logic triggers (For example: If your patient is over 60 and male, we can ask them different questions than we would ask a younger male or even a female the same age)

How to make a change

If you’d like to make a change or for more information – reply to one of our emails or fill in the form at the bottom of this article or even fill in your existing questionnaire indicating your changes in the boxes, then forward that to us.

Request Form

Click Request at the bottom of the example, or scroll to the bottom of this article to fill in the form.

TIP: If you would like a ‘super speed link’ to bypass the required fields on your form and test it quickly, let us know.

For more information about what’s included in the Premium Plan please click here.
Or if you want to upgrade from a Standard Plan to a Premium Plan, please use the upgrade form here.

Examples – PATIENT DETAILS:

PD1. Non-Binary Gender

Non Binary Gender - Preoperative Anaesthetic Assessment

Instead of just Male and Female (as listed on original members forms), we can also include a Non-Binary gender option
Example: add the words “Non-Binary” to the gender options
CREDIT – Dr Anna Pedersen
Request

PD2. Other Gender

Example: add the word “Other” and if selected ask “What were you assigned at birth?” (select) as well as “What do you identify with now?” (free text)
Request

PD3. Calculate Age from Date of Birth

Date of Birth Age - Preoperative Anaesthetic Assessment

Some original forms ask the Age and also the Date of Birth of a patient. We have the ability to only ask the Date of Birth and then in the questionnaire sent to you we can automatically calculate the age. Form questions can still be dependant on age (e.g. if the calculated age is <18, child questions can still be asked).
CREDIT – Dr Steve Clulow
Request

PD4. Private or Public Patient

Private Public - Preoperative Anaesthetic Assessment

You can ask if the patient will be a public or a private patient. You can also include an “I am unsure” option.
CREDIT – Dr Anna Pedersen
Request

Examples – CHILDREN:

C1. Parent DOB Warning

Email Invoice - Preoperative Anaesthetic Assessment

Warn the date of birth might be incorrect.
Parents sometimes fill in their own date of birth when filling out the questionnaire for their child. The form can display a warning if the answer to “Are you the patient?” is No (i.e. a parent filling out the form) and the date of birth entered calculates the age between 20 and 60.
CREDIT – Dr Chris McMahon
Request

C2. Replace Health Questions

Email Invoice - Preoperative Anaesthetic Assessment

If the patient is a child (under 13), remove some standard health condition questions (heart, diabetes, reflux, thyroid, neuro, arthritis, kidney, blood clots) and instead just ask if they have any health issues.
Example: Any other health issues? (this could include diabetes or any other issues affecting their health. Please be as detailed as possible)
CREDIT – Dr Nicola Doogan
Request

C3. Significant Issues in First 12 months

Child NICU - Preoperative Anaesthetic Assessment

Only show this question if the age is less than 16.
If Yes is selected, a detail / paragraph box can appear where the patient can provide more information
Example: Any significant medical issues in the first twelve months of life? (this can include prematurity, time in the Special Care Nursery (SCN) or Neonatal Intensive Care Unit (NICU), or admissions to hospital for any reason)
Request

C4. “Are you well” Question (split)

Child Sick - Preoperative Anaesthetic Assessment

When the patient is a child (under 13 years old), some members will ask, “Are you well?” differently.
Example: Have you had a cough or cold in the last 2 weeks?
If Yes 3 text boxes appear:
Do they have a fever currently?
Are they eating and drinking normally?
Are they playing as normal?

CREDIT – Dr Nicola Doogan
Request

C5. Anxiety

Email Invoice - Preoperative Anaesthetic Assessment

Provide the Anaesthetist with notice and also give assurance to the parent if the patient (a child under 13) is anxious about the procedure.
Example: Is your child particularly anxious about having an operation or anaesthetic? If Yes or Unsure is selected, a box will pop up – Please be reassured that Dr Doogan can give your child a medication before the operation to help your child to remain calm
CREDIT – Dr Nicola Doogan
Request

C6. Swallow Tablets

Email Invoice - Preoperative Anaesthetic Assessment

When the patient is a child (under 13 years old), ask if they can swallow tablets
Example: Can you swallow tablets? (is your child able to swallow tablets on their own)
CREDIT – Dr Nicola Doogan
Request

C7. Syndrome

Only show this question if the age is less than 16.
If Yes is selected, a detail / paragraph box can appear where the patient can provide more information
Example: Do you have a syndrome?
Request

Syndrome - Preoperative Anaesthetic Assessment

C8. Heart Question

Child Heart - Preoperative Anaesthetic Assessment

Only show this question if the age is less than 16 and also the other heart question (asking about heart attacks, pacemakers etc) can be removed
If Yes is selected, a detail / paragraph box can appear where the patient can provide more information
Example: Any trouble with your heart or cardiovascular system? (this could include murmurs, holes in the heart, past visits to a cardiologist, past heart surgery)
Request

C9. Breathing Question

Child Heart - Preoperative Anaesthetic Assessment

Only show this question if the age is less than 16 and also the other lungs / respiratory question can be removed
If Yes is selected, a detail / paragraph box can appear where the patient can provide more information
Example: Any breathing problems? (this could include asthma, bronchiolitis in last 3 months, snoring, obstructive sleep apnoea, cystic fibrosis)
Request

C10. Stomach Question

Child Heart - Preoperative Anaesthetic Assessment

Only show this question if the age is less than 16 and also the other GORD question can be removed
If Yes is selected, a detail / paragraph box can appear where the patient can provide more information
Example: Stomach Problems? (this could include gastro-oesophageal reflux disease (GORD))
Request

C11. Teeth

Email Invoice - Preoperative Anaesthetic Assessment

There are many options about teeth and dentition in the main questionnaire (loose teeth, chipped, braces, caps, implants, dentures, etc.). If the patient is a child, you may want to replace this question with a simplified tooth question.
Example: With regards to teeth – are there any loose teeth at the moment?
Yes – Loose tooth or teeth
No
CREDIT – Dr Nicola Doogan
Request

C12. Immunisation History

Only show this question if the age is less than 16. An upload box can also appear
Example: Please upload a copy of the child’s immunisation record. Alternatively you can note the last immunisation below or securely send the record to Dr xx later via the contact form on his profile page
CREDIT – Dr Chris McMahon
Request

Immunisation - Preoperative Anaesthetic Assessment

C13. Smoking Environment

Child Smoke - Preoperative Anaesthetic Assessment

By default, children are not asked if they smoke, however some Anaesthetists ask if anyone in their home smokes.

Child Smoke - Preoperative Anaesthetic Assessment

If yes is selected we can show a warning message (for a child) or a separate message for an adult if the smoking question is selected
Example (all): Does anyone smoke in your home/car environment?
Example (Child): Children should not be exposed to smoke for at least 48 hours prior and for 3 days after the procedure. There is correlation for children exposed to smoke to be at greater risk of respiratory complications during and after the procedure.
CREDIT – Dr Anna Pedersen, Dr Chris McMahon & other members
Request

C14. Other Problems

Child Brain - Preoperative Anaesthetic Assessment

Only show this question if the age is less than 16.
If Yes is selected, a detail / paragraph box can appear where the patient can provide more information
Example: Any brain, nerve or muscle problems? (this could include cerebral palsy, epilepsy, developmental delay, autism, behavioural problems)
Request

C15. Collect / Post Op

Child Brain - Preoperative Anaesthetic Assessment

Require (child) patients to confirm they have someone to collect and help them for 24 hours and they confirm they will avoid activities.
CREDIT – Dr Chris McMahon
Request

C16. Confirmation Message (Information Documents)

Email Invoice - Preoperative Anaesthetic Assessment

Include a link to more information, such as Anaesthesia for Children, in the confirmation email. The file will link to the member’s additional pages on their profile.
Example: Please click here to read a document regarding Anaesthesia for Children.
(sent to all patients where age is 13 or younger)
CREDIT – Dr Nicola Doogan
Request

Examples – COVID-19:

CV1. Have you had COVID-19?

Email Invoice - Preoperative Anaesthetic Assessment

Ask the patient if they have had Covid-19. We included an ‘unsure’ option if the patient had a negative RAT or PCR, but their household had COVID-19 and they believed they had it as well.
If YES or UNSURE is selected the below will appear:

Email Invoice - Preoperative Anaesthetic Assessment

Extra questions will appear if Yes or Unsure is selected, asking the date of diagnosis, type of infection, if they still have symptoms, and if they have been able to resume their regular exercise routine.
We then use the date to calculate the days and weeks between COVID-19 and the operation date (see separate notification update).
Updated to Standard Pre-Op March 2022
Request

CV2. Supercharge Your Notification

Email Invoice - Preoperative Anaesthetic Assessment

COVID-19 status is now included in the warning message (above the questionnaire). If yes, it appears in red to alert the Anaesthetist.

In addition, it lists the date of diagnosis and auto-calculates the number of days and weeks between the diagnosis and the operation date. If no operation date is listed, it will calculate from the diagnosis date to today’s date.
Updated to Standard Pre-Op March 2022
Request

CV3. “Are you well” Symptoms

COVID19 Warning - Preoperative Anaesthetic Assessment

Update the symptoms to include common COVID-19 symptoms
Example: Are you well at the moment?
(if your surgery is within the next two weeks please advise if you have had a recent cough, cold, sore throat, shortness of breath, runny nose, fatigue, muscle aches, pain, fever, loss of smell/taste or any other illness recently)

CREDIT – Dr Chris McMahon + updated with 2020 / 2021 / 2022 Covid symptoms
Request

CV4. Activities and Vaccination

Email Invoice - Preoperative Anaesthetic Assessment

We have updated the COVID-19 activities question. Please keep in mind that this section is optional and can be turned off.
Remove hot spot, add a household member option. If close contact or household member are selected, extra isolation questions will be asked. We have also added a vaccination status question.
Updated to Standard Pre-Op March 2022
Request

CV5. Receive a Warning

Novel coronavirus COVID-19 Anaesthetist screening Pre-Op Questionnaire

If patients mark yes to specific questions in your form, you can be emailed a warning on the pre-op questionnaire you receive. This warning can be in the body of the questionnaire, email or even in the subject line.
CREDIT – Dr Chris McMahon
Request

CV6. Simple Question

Novel coronavirus COVID-19 Anaesthetist screening Pre-Op Questionnaire

Add a short and simple text question asking if the patient has had COVID-19.
Example: Have you had a Covid-19 infection? If so when?
Request

CV7. Follow Health Directives

Novel coronavirus COVID-19 Anaesthetist screening Pre-Op Questionnaire

Before patients submit the form, require them to confirm they have no symptoms and will follow the Chief Health Officer directives.
CREDIT – Dr Chris McMahon
Request

CV8. Custom Confirmation Messages (2020)

Novel coronavirus COVID-19 Warning - Preoperative Anaesthetic Assessment

If patient’s mark yes to specific questions in your form, you can show them a customised confirmation message on submission and also send them a customised email.
CREDIT – Dr Chris McMahon
Request

CV9. Extra Questions Page (2020)

Novel coronavirus COVID-19 Warning - Preoperative Anaesthetic Assessment

A detailed COVID-19 questions page can be added to your questionnaire asking whichever questions you feel appropriate. For instance if you ask if they have had a cough, if Yes is selected you can ask them if they bring up phlegm etc. Then based on these answers you can customise the confirmation message they see and are emailed plus also on the pre-op questionnaire you receive.
CREDIT – Dr Chris McMahon
Request

CV10. Confirmation Warning (2020)

COVID19 Warning - Preoperative Anaesthetic Assessment

Notify the patient to contact their surgeon if they have been overseas or have COVID-19 symptoms.
This notification can appear on the confirmation page (seen as soon as form submitted) and/or in the confirmation email they receive
CREDIT – Dr Chris McMahon
Request

CV11. Travel Question (2020)

Novel coronavirus COVID-19 Warning - Preoperative Anaesthetic Assessment

Ask patients if they have been overseas (or you can ask if they have travelled at all) in the last 14 days.
If Yes or Other is selected the patient can advise details of where they have been and transited through. The Other option is in case the patient will be planning on travelling but hasn’t yet or even if they wish to mention if e.g. their partner has recently travelled.
Request

Examples – OPERATION(S) DETAILS:

OD1. Previous Anaesthetics & Problems

Anaesthetic Problems and Complications - Preoperative Anaesthetic Assessment

Ask specifically if they have had problems, add a warning box asking the patient to ensure they mention any problems plus mention example complications in the details question.
Original questionnaires asked about anaesthetic problems as well as other issues in the question description and wasn’t as obvious to some patients.
Example: Have you ever had any anaesthetic complications or problems?
Plus a warning box: Warning Box: If you have ever had any reactions to or issues with receiving anaesthesia in the past, please ensure you detail this below
Then update the description to: Please list the details of your past surgical procedures, in particular if you have undergone a lap band (laparoscopic gastric banding) procedure. If you have ever had any anaesthetic problems or anaesthetic complications (e.g. severe nausea/vomiting, perioperative cardiac events etc) please ensure you mention them here including the name of the hospital(s). Providing these details can help in retrieving previous anaesthetic records meaning past problems could potentially be avoided
Request

OD2. Previous Procedures List

Pre-Op Health Questionnaire anaesthetist patient previous surgeries list

Amend the paragraph box for previous procedures to be in a list format. For example asking Operation, Hospital, Year and Surgeon
CREDIT – Dr Chris McMahon
Request

OD3. Repeat Procedure Question

Repeat Grommets - Preoperative Anaesthetic Assessment

Ask the patient if the operation is a repeat procedure.
If Yes is selected, a detail / paragraph box can appear where the patient can provide more information
Example: Is this operation a repeat procedure for an existing condition (e.g. second set of grommets)?
CREDIT – Dr Steve Clulow
Request

OD4. Change Questionnaire based on Operation

Repeat Grommets - Preoperative Anaesthetic Assessment
Repeat Grommets - Preoperative Anaesthetic Assessment

If a patient mentions specific words in their procedure or clicks on a special link from your profile page, we can completely alter the questionnaire shown to them.
Example: We have detected your procedure is an Endoscopy, Gastroscopy, Colonoscopy, ERCP or Endoscopic Ultrasound (EUS). Is this correct? A special questionnaire is available for patients having an Endoscopy, Gastroscopy, Colonoscopy, ERCP or Endoscopic Ultrasound (EUS). Please select YES below if you are having this type operation.

Repeat Grommets - Preoperative Anaesthetic Assessment

We can completely remove questions for example on the third (health history page) we can only ask them if they have diabetes. We can remove the third page (teeth, file uploads, Covid). And also minimise the last page (financial questions).
CREDIT – Dr Jay Bond
Request

OD5. Stay Overnight

Repeat Grommets - Preoperative Anaesthetic Assessment

Ask the patient if they are planning to stay overnight in hospital. If No, ask them if they have someone to collect them from hospital and who can help them for the first 24 hours after discharge
CREDIT – Dr Josephine Maria
Request

OD6. Current Inpatient

Repeat Grommets - Preoperative Anaesthetic Assessment

Ask the patient if they are currently a hospital inpatient. If yes, ask which hospital and ward.
CREDIT – Dr Josephine Maria
Request

Examples – MEDICATIONS:

M1. Medication List

Pre-Op Health Questionnaire anaesthetist patient medications list

Amend the paragraph box for medications to be in a list format. For example asking Drug Name, Dose, Time of Day and if they Take Regularly.
The Time of Day and Take Regularly options can be dropdown options
CREDIT – Dr Chris McMahon
Request

M2. Medications Upload

The default medications paragraph box can ask patients to tick a box if they would like to upload an image of a GP letter (as many include the medications on it already).
Example: If you have a medication list from your GP please upload it here, Alternatively, please detail each medication (or any other medications you take) with the strength taken and how often you take it
Request

M3. Non-prescription Medications

Non Prescribed Medications - Preoperative Anaesthetic Assessment

Ask the patient if there are any other non-prescribed medications they take.
If Yes is selected, a detail / paragraph box can appear where the patient can provide more information
Also if Yes is selected, a warning message can show
Example: Do you take regular non-prescribed medications? (this includes all herbs and vitamins like Gingko, Echinacea etc.)
If Yes is selected = Please detail each with the amount taken and how often you take it
Also show a warning box if Yes is selected = Please cease all non-prescribed medications for at least a week prior to your operation due to the effect they have on bleeding
CREDIT – Dr Chris McMahon
Request

M4. Pain Medications

Email Invoice - Preoperative Anaesthetic Assessment

Add an “Unsure / I don’t take pain relievers” option. Some patients have left feedback saying they rarely need pain medications and are uncertain how to answer this question.
Updated to Standard Pre-Op March 2022
Request

M5. Medications / Surgeon question

Cease Medications - Preoperative Anaesthetic Assessment

Ask the patient if they have had any advice from the surgeon on which medication to cease plus even display another warning message
Example: What medication has your surgeon advised you to cease? (Please also include details on when your surgeon has advised you to take the last dose of that medication.)
Plus a warning box: Please note that you may receive advice from me that requires you to not take other medication the day of or day prior to your operation.
CREDIT – Dr Chris McMahon
Request

M6. Medications Warning

Cease Medications - Preoperative Anaesthetic Assessment

Show a box directly above the medications question warning patients they may need to cease medications
Example: Please check with your surgeon if you are required to cease medications which increase bleeding e.g. (not limited to) Clopidogrel, apixaban, warfarin.
CREDIT – Dr Chris McMahon
Request

M7. Medications Reminder (blood thinners)

Cease Medications - Preoperative Anaesthetic Assessment

Underneath the medications question, add an extra question to remind patients they must advise blood thinners, anticoagulant or anti platelet medications
Example: Are you on any blood thinners, anticoagulant or anti platelet medications?
(this could include, but is not limited to, heparin, warfarin, rivaroxaban, dabigatran, apixaban, enoxaparin, aspirin, clopidogrel, ticagrelor). It is very important that I know this information. If you have not already listed this medication in your medications list above, please make sure you include it here.

CREDIT – Dr Jay Bond
Request

M8. Medications Reminder (diabetes)

Diabetic Medications - Preoperative Anaesthetic Assessment

Underneath the diabetes question, add an extra question to remind patients they must advise diabetic medications
Example: If you use insulin and/or tablets, please advise your insulin and medication doses
It is very important that I know this information. If you have not already listed this medication in your medications list above, please make sure you include it here.

CREDIT – Dr Jay Bond
Request

Examples – HEALTH HISTORY:

HH1. “Are You Well” – multiple changes

Some members change the period in question (currently the default is 2 weeks)
Example: If your surgery is within the next three weeks../ Have you been sick in the last three weeks..

Respiratory problems - Preoperative Anaesthetic Assessment

Another option is to ask about respiratory tract infections within the last two weeks and then also ask about a cold or flu in the last six weeks.
If Yes is selected for either, a detail / paragraph box can appear where the patient can provide more information
Example: Any significant respiratory tract infections within the last two weeks? (significant symptoms which could impact on the safety of your anaesthetic include fevers, rigors (shivering sweats), chesty moist productive coughs, shortness of breath, or being obviously unwell. Note – do not select ‘Yes’ for a simple cold or runny nose)

Also:
Example: Any cold or flu symptoms in the last six weeks? (including a simple cold, runny nose, wet or dry cough, fever or just feeling generally unwell)
Then small boxes can pop up asking for more details:
What were your symptoms? (e.g. headache, congested, sputum production, cough etc)
How do you feel now? Do you still have a cold or flu?
How long since your cold or flu finished?
And a paragraph box:
Please provide any other details

Respiratory problems - Preoperative Anaesthetic Assessment

Also:
Example: Are you currently sick or suffering from a cough, runny nose, sore throat, fevers, cold, fatigue, muscle aches, pain or headache? If Yes or Other is selected, a box pops up “Please provide details
CREDIT – Dr Anna Pedersen & other members
Request

HH2. “Other” Options

Email Invoice - Preoperative Anaesthetic Assessment

The option “other” can be added to Yes / No questions. Patients sometimes indicate they don’t fit into the Yes / No options, for example if they had their thyroid removed. This should help to avoid any confusion for these patients.
Updated to Standard Pre-Op March 2022
Request

HH3. Obstructive Sleep Apnoea

Obstructive Sleep Apnoea OSA - Preoperative Anaesthetic Assessment

Instead of the standard “Any trouble with your lungs or respiratory system? (this could include asthma, obstructive sleep apnoea (OSA) with or without CPAP mask use, or smoking-related problems)” some members ask about OSA (and asthma – see below) separately before this question, plus include a warning
Example: Do you have known Obstructive sleep apnoea (OSA)?
– Have you been recommended to use a CPAP machine? 

If Yes is selected we can say “Do you own a CPAP machine?” and even show a note or warning message “Please bring your CPAP mask with you to hospital as it may to assist your recovery from general anaesthesia
Then the lung question is changed to add ‘other’: “Any other trouble with your lungs or respiratory system?
CREDIT – Dr Anna Pedersen
Request

HH4. CPAP Warning

Email Invoice - Preoperative Anaesthetic Assessment

Change the wording from do you ‘own’ a CPAP machine to do you ‘have’ one. In addition, include a prominent warning to patients that they need to bring their mask and machine to the hospital.
Example: Important: Bring your CPAP mask and machine with you to hospital as it may assist your recovery from general anaesthesia
Updated to Standard Pre-Op March 2022
Request

HH5. Asthma Questions

Asthma 2 - Preoperative Anaesthetic Assessment

By default asthma is asked in the lung question. If Yes is answered then a paragraph box usually appears. Some members instead ask separately about OSA and asthma. Alternatively the lung question options Yes / No can just be changed to multiple choice options:
Example: Yes – Asthma
Yes – Obstructive Sleep Apnoea (OSA)
Yes – Other lung trouble
No

If the patient answers Yes to asthma, other questions and options appear
Example: Select all that apply
– A full canister of my reliever puffer (e.g. Ventolin) lasts less than a month
– I wake up during the night because I need to use my reliever puffer (e.g. Ventolin)
– I have required oral steroid tablets / liquid (e.g. prednisone or prednisolone) to treat my asthma within the last 3 months
– I have previously been admitted to Intensive Care because of my asthma
– Anti-inflammatory medicines (e.g. Nurofen, Voltaren, Mobic or Celebrex) provoke or make my asthma worse
– None of the above options apply to me

Asthma workup - Preoperative Anaesthetic Assessment

Or other questions could appear:
Have you ever had an ‘asthma attack’?
If Yes = How often have you had an ‘asthma attack’ and when most recently?
Have you ever been to hospital because of asthma?
If Yes = When was the most recent time and have you ever been you admitted overnight to hospital because of asthma?
CREDIT – Dr Anna Pedersen & other members
Request

HH6. Snoring

Snore - Preoperative Anaesthetic Assessment

Add a snoring question
Example: Do you ever snore?
With the options: Yes, No, Not Sure
CREDIT – Dr Anna Pedersen
Request

HH7. Rheumatoid

Bleeding - Preoperative Anaesthetic Assessment

Instead of just asking if Rheumatoid arthritis, we can add other conditions here too.
Example: Rheumatoid arthritis, osteoarthritis or any other musculoskeletal issues?
CREDIT – Dr Josephine Maria
Request

HH8. Chronic Pain

Bleeding - Preoperative Anaesthetic Assessment

Ask the patient if they have Chronic pain issues.
CREDIT – Dr Josephine Maria
Request

HH9. Excessive Bleeding Descriptions

Bleeding - Preoperative Anaesthetic Assessment

Adjust the blood clot and excessive bleeding description to mention other conditions. By default the description says ‘(this could include deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia or another condition)’
Example: Do you have a history of blood clots or excessive bleeding or any condition that may increase your risk of these? (e.g. deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia, thalassaemia, von Willebrand and others)
CREDIT – Dr Anna Pedersen
Request

HH10. Recent Blood Test

Recent Blood Test - Preoperative Anaesthetic Assessment

Ask all patients if they have had a recent blood test, or only ask those that meet your requirements (e.g. are on medications, have selected yes to certain health problems).
If Yes is selected, we can list your local blood test companies as a checkbox list for the patient to select, including an ‘other’ free space option.
Example: Have you had blood tests done recently? then Please select who the blood test company was..
CREDIT – Dr Chris McMahon
Request

HH11. Pregnancy

Our very first questionnaire, which some of our original members are based on, only asked a yes / no option for pregnancy. An extra question could be added asking how many weeks (if yes is selected)
Example: If you are pregnant, how many weeks are you / would you be today?
Request

HH12. Gastric Band Surgery

Gastric Band - Preoperative Anaesthetic Assessment

Add gastric band to the default GORD question and also include it as a separate option.
Currently the GORD question by default asks if the patient has “Gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia?”
Then if Yes is selected, usually 4 checkboxes appear regarding the burning sensation, we can also add gastric band to this
Example: Gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia, or have you had gastric band surgery?
If Yes is selected, an extra option appears = I’ve had a gastric band or gastric sleeve surgery
CREDIT – Dr Anna Pedersen
Request

HH13. Shortness of Breath

Originally there were only two options to the “Shortness of breath climbing less than 2 flights of stairs or whilst walking for 30 minutes on flat ground?” question – Yes and No.
This question is asked of all ages.
We had feedback from a few patients recommending we add an “other” option to this (e.g. for a paraplegic or for a baby that hasn’t learnt to walk yet). This “other” option can be a free form text box where the patient can elaborate.
Request

HH14. Exercise Ability

Exercise - Preoperative Anaesthetic Assessment

Ask the physical activity level of patient and if an activity is selected a box can also appear advising them not to exercise the morning of the procedure
Example: What type of physical activity are you able to do?
Options:
Light intensity – e.g. walking
Moderate intensity – e.g. swimming, tennis
Vigorous intensity – e.g. jogging, aerobics
None – I am not able to do any exercise

If any intensity is selected, a note can pop up:
Please do not exercise the morning of your operation as you are likely to be fasting and will subsequently be dehydrated
CREDIT – Dr Chris McMahon
Request

HH15. Liver Condition

Liver - Preoperative Anaesthetic Assessment

Liver - Preoperative Anaesthetic Assessment

The default questionnaire asks many questions about other problems (lungs, diabetes, GORD, Thyroid, Neurological etc). Some members have also chosen to add a Liver question under the section ‘Do you have, or have you ever had, any of the following?’
Example: Liver disease? (this could include fatty liver or cirrhosis)
Example: Liver condition?
If Yes is selected = Please provide details (make sure you include your Hepatologist, Gastroenterologist or Liver Doctor’s name and contact details if applicable)
CREDIT – Dr Josephine Maria & other members
Request

HH16. Heart Question – Strokes + Cardiologist

Heart Cardiologist - Preoperative Anaesthetic Assessment

The Standard questionnaire asks about strokes in the question regarding “Neurological Condition?” Some members also ask in the heart question if the patient has had a stroke. One member also has updated how this question is asked to include ‘Any heart problem or have had any reason to see a Cardiologist in the past?
Request

HH17. Heart Conditions

Heart Cardiologist - Preoperative Anaesthetic Assessment

Change the Yes option to multiple tick boxes.
CREDIT – Dr Chris McMahon
Request

Heart Cardiologist - Preoperative Anaesthetic Assessment

Ask the heart question as a series of check boxes (if they have heart trouble), and then ask other questions based on the options selected.
Example: If Yes > Have you had any of the following: (please select all that apply) High blood pressure, Heart surgery, Pacemaker, Defibrillator, Cardiac Stent(s), Vascular disease in any arteries, Peripheral Arterial Disease, Procedures on any other arteries (such as your aorta or leg arteries), Other
If pacemaker = When was your pacemaker last checked?
If heart surgery = If yes to heart surgery, please provide as many details as possible – when this occurred, – if you have had a heart valve replacement, please indicate whether it is a tissue or mechanical valve
CREDIT – Dr Josephine Maria
Request

HH18. Cancer

Cancer - Preoperative Anaesthetic Assessment

Ask if the patient has had cancer treatment.
If Yes is selected, extra questions can appear so the patient can provide more information
Example: Have you had cancer treatment?
Then if yes a new page can show with more questions
– In which part of your body was cancer identified?
– Did you have Chemotherapy?
– What was the type of Chemotherapy?
– Did you have Radiation Therapy?
– Did you experience reduced exercise capacity, difficulty breathing once you started Chemotherapy?
– Did you get reviewed by a specialist, have an echocardiogram (ultrasound of the heart), or lung tests?
–> Who was the specialist?
–> Where were the tests done?
–> Have these symptoms resolved?

CREDIT – Dr Chris McMahon
Request

Bleeding - Preoperative Anaesthetic Assessment

Alternatively you could ask if the patient has had cancer treatment and if Yes, include a simple text box for the patient to provide further details.
CREDIT – Dr Josephine Maria
Request

HH19. Smoking / Drinking

Drugs Recreational Substances - Preoperative Anaesthetic Assessment

In the original questionnaire the smoking and drinking question was a single question where the patient can answer Yes / No combinations and then a box can pop up asking how much in an average week.
Some members, and the new Standard questionnaire, split this into two separate questions.
Example (adults only): Do you smoke?
Example (adults only): Do you regularly drink alcohol?
If Yes = What do you smoke and how much did you smoke in the last week? / If yes, please detail what you drink and approximately how many alcoholic drinks you had in the last week
Request

HH20. Smoking Warning

Adult Smoke - Preoperative Anaesthetic Assessment

Example (Adult – if they smoke): The knowledge from international research suggests that not smoking for a time prior (48hrs) to your operation results in significant change in the intraoperative and post-operative course of lung complications.
CREDIT – Dr Chris McMahon
Request

HH21. Drinking Warning

Adult Smoke - Preoperative Anaesthetic Assessment

Adult Smoke - Preoperative Anaesthetic Assessment

Warn the (adult) patient that you need to know accurately their alcohol intake.
Example: Firstly, how many days per week do you regularly drink alcohol? With drop down options.
Then if anything except they “I don’t drink” is selected a new box will pop up:
Secondly, how many drinks do you have on a typical day? (please describe how many drinks, what type and if it is different on weekends)
CREDIT – Dr Josephine Maria
Request

HH22. Recreational substances question and warning

Drugs Recreational Substances - Preoperative Anaesthetic Assessment

This question can only be shown if the age is greater than 16.
If Yes is selected another question / details box can appear. A warning message can also be displayed
Example: Do you use recreational substances?
If Yes selected = Please included details like when and what did you last use?
A Warning box can also display:
It is important to avoid recreational substances, at least in the week prior to your operation
CREDIT – Dr Chris McMahon
Request

Drugs Recreational Substances - Preoperative Anaesthetic Assessment

Alternatively you can also ask about herbal medicines or any other non-prescribed substances in this question.
CREDIT – Dr Josephine Maria
Request

HH23. Infectious Diseases

Bleeding - Preoperative Anaesthetic Assessment

Ask the patient if they have ever been diagnosed or treated for an infectious disease.
CREDIT – Dr Josephine Maria
Request

Bleeding - Preoperative Anaesthetic Assessment

Ask the patient if they live with any transmissible viral infections.
CREDIT – Dr Chris McMahon
Request

HH24. Teeth Options

Email Invoice - Preoperative Anaesthetic Assessment

Due to patient feedback, reword “+/- fillings” to “with or without fillings”. Add wire retainer to the options.
Updated to Standard Pre-Op March 2022
Request

HH25. Open Mouth

Email Invoice - Preoperative Anaesthetic Assessment

Ask patients if they can open their mouth fully.
Example: Do you have any limitation with opening your mouth fully? If yes is selected, a please provide details box will pop up
Request

HH26. My Health Record

My Health Record - Anaesthetist

The question “Are you entitled to access Medicare..” exists in the Standard questionnaire however by default we don’t ask the Medicare number. To access a patient’s My Health Record you many need the patients Medicare number – we can add this question if required, and only for those that mark they have a My Health Record.
Example: Are you entitled to access Medicare..
If Yes – Do you have a My Health Record?
If Yes – Please provide your Medicare number
CREDIT – Dr Anand Thilla
Request

HH27. Shorter + General Box

My Health Record - Anaesthetist

Remove irrelevant questions from your health history section and ask a general health issue question instead.
Example: Any other health issues you wish to mention? (Yes / No) then If yes, please provide details
Request

HH28. Reword Relatives

My Health Record - Anaesthetist

Reword the question asking if any blood relatives have had problems to be more specific – serious / life-threatening reaction.
Example: Have any of your blood relatives had a serious, life-threatening reaction to an anaesthetic?
Request

Examples – FINANCIAL / BILLING:

FB1. Email Invoice Checkbox

Email Invoice - Preoperative Anaesthetic Assessment

If the patient enters an email address into the form, we can show a checkbox asking if they give authority for their invoice to be sent via email
Example: I give authority for my invoice (if applicable) to be sent via email
CREDIT – Dr Anna Pedersen
Request

FB2. IFC Automated (Email your Billing Secretary)

Billing secretary - Preoperative Anaesthetic Assessment

If you have a billing secretary that provides quotes to patients, we can create a notification to go to your billing secretary with the patient’s basic (no medical data) details.
Example: (if patient selects yes) Yes – Please send me an estimateExample: If the patient selects Yes to a request for a quote, we can email your billing secretary their basic contact details (no clinical data)
CREDIT – Dr Brenton Coats
Request

FB3. IFC Advanced (for No Gap Procedures)

IFC Quote - Preoperative Anaesthetic Assessment

Our form is built so that we can provide you complete customisation – for example if there is a common procedure you always No Gap, or if there is a procedure you always No Gap but only with a particular surgeon and/or only at a particular hospital, we can base different values or even options to this question based on your criteria.
We can either show what the fee would be, do a range or simply given the fee option.
Example: only if Endoscopy and/or Colonoscopy is written as the procedure, we can show the option:
N/A – Endoscopy / Colonoscopy (No Additional Fee)

Example: (if Northern Beaches Hospital is written as the hospital and the procedure is X / surgeon is Y), we could even show the option:
N/A – I am a public patient

CREDIT – Dr Anna Pedersen
Request

FB4. IFC Other Changes

IFC Patient - Preoperative Anaesthetic Assessment

By default the form asks the patient if they would like a quote or estimate with the options;
“Yes”, “No” or “N/A – I have already paid” (which then asks for details of how paid)
There are many ways you can change these options to suit your needs
Example: (change the question to) If you haven’t already been contacted by our staff, would you like an estimate of the Anaesthetic Fee pre-operatively? Plus the options;
* I have already been given an estimate of fees
* Yes – Please send me an estimate
* No – I’m happy to proceed as is
* Not required as I am being fully covered by a Workers Compensation / Defence Force / Third Party Insurance scheme

Example: (remove the question and instead display a note) Your surgeon has advised that you should call the office of on XXX and request a quote.

Pre-Op Health Questionnaire anaesthetist medicare

Example: Reword to Would you like an email quote or estimate of the Anaesthetic Fee pre-operatively (your gap invoice will arrive approximately 3-4 weeks after surgery. For some procedures prepayment is required.)
CREDIT – Dr Anna Pedersen & other members
Request

FB5. Medicare Number (and identifier)

Pre-Op Health Questionnaire anaesthetist medicare

Add a question asking for the patient’s Medicare Number early on in the form. When a number is entered, a question asking for the Medicare Identifier number is then asked
CREDIT – Dr Chris McMahon
Request

FB6. Display Payment Details

Pre-Op Health Questionnaire anaesthetist medicare

When the patient is asked if they would like a quote, it usually then asks them how they would like to pay, with Direct Deposit as an option. For patient’s who select Direct Deposit as the payment method, we can include your payment details underneath and/or on the confirmation page and/or in the confirmation email they receive
Example: Payment Details:
– Direct Deposit:
BSB xxx
Act xxx

CREDIT – Dr Muhammad Essop
Request

FB7. Display your Billing Service’s Details

Pre-Op Health Questionnaire anaesthetist postal address

Provide the patient with the contact information for billing questions.
Example: At the end of the questionnaire, before the patient hits submit

Pre-Op Health Questionnaire anaesthetist postal address


Example: Also in the confirmation email

CREDIT – Dr Chris McMahon
Request

FB8. Postal Address

Pre-Op Health Questionnaire anaesthetist postal address

While this is now on all new questionnaires, some original members do not ask if the patient has a different postal address.
Request

Examples – DOCUMENTS:

D1. File Upload Improvements

Email Invoice - Preoperative Anaesthetic Assessment

Upgrade the Upload Files section to be drag and drop, and faster. Also, expand the types and the number of documents a patient can upload. Patients can also see the progress of file upload, which loads faster (rather than on page change). Additionally a better description of how to upload a file has been added (due to patient feedback).
(Files are still sent with the questionnaires to you, as we don’t store patient data on our servers for security reasons).
Updated to Standard Pre-Op March 2022
Request

D2. ANZCA Info Documents to Profile

ANZCA documents - Preoperative Anaesthetic Assessment

ANZCA have created a range of anaesthesia documents for patients (for example). We have received written permission from ANZCA to link these documents to your forms and profile pages. Please let us know which documents you would like included. We can even show the patient different documents based on their age / procedure / surgeon.
Example: If the patient is under 18, we can show the confirmation message and email the link to the Anaesthesia and Children ANZCA document
CREDIT – Dr Anna Pedersen
Request

D3. Confirmation Message (Send Risk Documents)

Email Invoice - Preoperative Anaesthetic Assessment

Email Invoice - Preoperative Anaesthetic Assessment

Email Invoice - Preoperative Anaesthetic Assessment

Email Invoice - Preoperative Anaesthetic Assessment

We can completely customise the confirmation messages patients are shown when their form is submitted
Example: If the patient mentions a certain procedure and/or surgeon, we can show them a different confirmation message (and patient confirmation email) or send them a link to your document on that procedure (e.g. joint replacement surgery) or even provide them a link to your side-effects and risk document
CREDIT – Dr Josephine Maria, Dr Nicola Doogan & other members
Request

D4. Consent for Medical Records

ANZCA documents - Preoperative Anaesthetic Assessment

Extend the consent to contact other doctors to also include “access your medical records”.
Example: Do you give your consent for me to contact your other doctors, or to access your medical records if required?
CREDIT – Dr Callum Gilchrist
Request

D5. Fee Explanation Document

ANZCA documents - Preoperative Anaesthetic Assessment

We can upload a Fee Explanation document to your profile page. You can also refer to this in your questionnaire and/or the confirmation email patients receive after filling in your form.
Request

Examples – ADMIN:

A1. Introduction Text

Email Invoice - Preoperative Anaesthetic Assessment

Update the wording at the top of questionnaire to clarify what users need to do and to also mention they can add more information or ask questions in the final section.
Updated to Standard Pre-Op March 2022
Request

A2. Add to Hospital Record

Email Invoice - Preoperative Anaesthetic Assessment

Update the wording before patients start the questionnaire, advising them how you handle their information and that it will be added to their hospital record.

Email Invoice - Preoperative Anaesthetic Assessment

Again, let patients know how you will handle their information and that it will be added to their hospital record before they submit.
CREDIT – Dr Chris McMahon
Request

A3. Contact Wording

Email Invoice - Preoperative Anaesthetic Assessment

Change the question asking if the patient would like a phone call to be less specific, so you have greater flexibility in how you contact the patient.
CREDIT – Dr Chris McMahon
Request

A4. Confirm Collect, Do Not Drive Warning

Pre-Op Health Questionnaire anaesthetist patient drive

Require patients to confirm they have someone to collect and help them for 24 hours and that they confirm they will not drive for 24 hours after surgery.
Alternatives to this is a warning message if “No” options are provided stating they must organise this now or their procedure will not go ahead
CREDIT – Dr Chris McMahon
Request

A5. Collect and Post Op Warnings

Pre-Op Health Questionnaire anaesthetist patient drive

The Standard questionnaire asks “Do you have someone to collect you from hospital and who can help you for the first 24 hours after discharge?” Some Anaesthetists have changed the wording of this, or even displayed different warning messages.
Example: Do you have a responsible adult who can collect …

  • If the patient selects No, display a warning: Please note: In order to go ahead with your procedure you must have a responsible adult collect you and stay with you. Please make arrangements for this now.
  • Or, if the patient is 18+, display a warning: For the 24 hours after your anaesthetic, we advise that you do not drive, sign important documents or undertake activities where coordination is required.
  • Or, if the patient is <18, display a warning: For the 24 hours after the anaesthetic, we advise children should avoid activities where coordination is required. This may include, but not limited to, avoiding climbing, bike riding, swimming, horse riding, gymnastics, etc.

Request

A6. Agree “Not To Do” Post Op

Pre-Op Health Questionnaire anaesthetist patient drive

Require patients to confirm they will agree not do specific things post op.
CREDIT – Dr Josephine Maria
Request

A7. Other Warnings

We can display any alert you require either as a standard alert (shown to all) or a smart alert (only shown to those that follow your criteria e.g. medication name listed, previous anaesthetic problems marked yes, over a certain age etc)
Example: If your surgery is complex in nature or you have health concerns which require multiple medications or visits to the specialist in the last 6 months, the practice secretary may advise you that they will get back to you after Dr XXX has discussed your case with your surgeon.
CREDIT – Dr Chris McMahon
Request

A8. Advise all Patients

Email Invoice - Preoperative Anaesthetic Assessment

Some Anaesthetists call all patients. Instead of asking the patient if they would like a phone call, we can add a warning box before the end of the questionnaire. So the patient knows to expect a phone call and can prepare any questions they may have.
Request

Risks of Anaesthetic - Preoperative Anaesthetic Assessment

Ask patients to confirm they have read your information on the risks of anaesthesia.
If you provide us with a document that details the risks, we can then upload this to your Extra Pages.
Patients can either be asked if they have read the document (yes / no – see blow) or we can also upload the risks to a scrolling box that they can (or must) tick to confirm they have read the risks
Example: (risks document also in a scrolling box): I have read and accept the above risks
CREDIT – Dr Anna Pedersen
Request

Risks of Anaesthetic - Preoperative Anaesthetic Assessment


Upload a document to a scrolling box the patient must confirm they have read and understand the Anaesthetics, Side-Effects and Risks
CREDIT – Dr Josephine Maria
Request

Risks of Anaesthetic - Preoperative Anaesthetic Assessment


Example: Have you read the risks of anaesthesia section on my FAQ page? (please see Dr xxx FAQ page for this information. I would encourage you to ask me any specific questions that you may have) – Yes / No option
CREDIT – Dr Callum Gilchrist
Request

Examples – OTHER:

Z1. Flag your Notification Message

Email OSA - Preoperative Anaesthetic Assessment

We can completely customise the notification you receive
Example: If the patient mentions they have had certain anaesthetic problems before or select they have OSA, the notification you receive can have “HIGH RISK” or even “OSA – OVERNIGHT” in the subject line or any other notes at the top of the notification
Request

Z2. Profile Image (e.g. list of hospitals)

Anaesthetist profile image - Preoperative Anaesthetic Assessment

If you don’t have a profile image available, instead of a default graphic we can create you an image showing your list of hospitals. Just contact us with the information you would like and we can create it for you in the below style.
Example: image above
Request

Z3. Patient Review / Copy of Form

Add the ability for patients to review the information before they hit submit. Example: Would you like to review your answers before submitting the form?
On the review page they can then check their answers and also print out a copy of their responses before submitting the form.
We can also turn on the ability to send a copy of the questionnaire to patients. (For security reasons we do not send a copy to patients by default / in case they enter an incorrect email address, or use their work email which someone else is checking)
Request


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