Demo – Pre-Op Health Questionnaire

"*" indicates required fields

Demo Tip: Simply fill out the form and click Submit to see how your form will arrive in your inbox.
Required fields have been turned off so you can submit this form without filling in all the fields.
Normally questions marked with a * must be filled in for patients to progress through the form.

Please note: This form can be completed from ANY device

If you would rather complete this on a bigger screen, please click ‘Save Your Form’ below or visit anaestheticgroup.com.au from your desktop or laptop

To use this demo form properly, please visit this demo starting page first.

You will often be asked to complete a similar questionnaire by the hospital before admission for their own records – this is not provided to your Anaesthetist. To ensure your Anaesthetist is properly prepared for your anaesthetic, please complete this pre-op health questionnaire to the best of your ability.

This questionnaire should take approximately 18 minutes to complete. We strongly recommend you click the “Save Your Form” button at the bottom of every page whenever you need to step away to check information (this form is designed to timeout after inactivity for security and privacy reasons), or if your internet connection is unstable.

You can complete your questionnaire faster if you have the following ready:
– Details of your current medications, weight (kg) & height (cm)
– Information about your health conditions and previous procedures
– Your health care cards (Medicare card, private health fund etc)
– Contact details of your usual Doctors (GP & Specialists)
– A scanned PDF / JPG or photo of any results, medication lists or letters you wish to send your Anaesthetist

Tips:
* To return to a previous page, only click the “PREVIOUS” button
* Some fields are mandatory and marked with an asterisk (*)
* When you click “Save Your Form“, your entered data will not be lost if you leave your device. You will also see a unique link that can be clicked, copied or emailed. The link can also be used on a different device (eg. for taking pictures from your phone or checking dates, heights, or weights).
* You can send extra files to your Anaesthetist later via the contact form on their profile page
* To provide additional information or ask questions to your Anaesthetist, click YES to the final question “Is there anything else you would like to mention?”.

🔒 This is a secure form. Once you submit this form, it is immediately sent to your Anaesthetist and for added security Anaesthetic Group does not store your completed questionnaire.

The Anaesthetist selected is:*

Hidden

Demo Email

Patient Details:

Patient's Name*

First Last

Are you the patient?*

Yes

Your Name

Relationship to Patient

Please complete all of the following questions based on the patient
ie. when the question refers to “you” please describe the patient’s health.

Gender*

Female

Male

Other

Demo Tip: The questionnaire will ask an additional pregnancy question(s) for patients between 17 and 70 years of age when Female is selected

What were you assigned at birth?

Female

Male

What do you identify with now?

Date of Birth*

(select your date of birth using the calendar icon or enter it as dd/mm/yyyy eg. 01/05/1981)

In case you are a parent filling in the form for your child, please make sure you enter your child’s date of birth and not your own

Demo Tip: In your notification, the patient’s age is automatically calculated for you. The “Age” field below is not displayed to your patient.

Age (hidden – auto calculated)

Phone Number(s)*

Please check your email address – You entered “.con” but normally it’s “.com“
To receive confirmation of your submission, you must enter a valid email address. (However, if your email address really does contain a “.con” inside it, please disregard this message).

Operation Details:

Surgeon*

Hospital

Operation*

(the procedure being performed)

Date of Operation

(select the operation date using the calendar icon or enter it as dd/mm/yyyy eg. 01/12/2024)

Demo Tip: The patient’s “Age in months” on operation date will appear on your notification, if the patient is 2 years of age or younger, and the date of the operation is entered

Age in Months (hidden – auto calculated for <2y)

This field is not displayed to the patient. Your notification will display the patient’s age in months automatically.

Why are you having this operation?

(what symptoms or diagnosis made you decide to undergo this procedure?)

Stop!! You have entered the wrong Date of BIRTH above.
The age we calculated for you is “0” years old. Please scroll up and correct the “Date of Birth” entered.

However, if this form is for a baby, please scroll up and fix the second question, as you answered it incorrectly.

Or, please tick the box below to confirm the date of birth is correct*

I confirm my date of birth above is correct and this form is being filled in for a baby

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There is normally a page break here + the option for patients to save their form

Patient Information:

STOP! The questions in this questionnaire differ greatly depending on whether the patient is an adult or a child. If you see this message, you have not entered a date of birth. To accurately show a demo of questions, a date of birth (eg. for an adult or child) is required. Please enter an age under 2 (eg. 2/2/2024) to see the full paediatric demo. Go to Date of Birth Question

PAEDIATRIC DEMO ACTIVATED
Change the Date of Birth entered, to see the Adult version

Height (cm)*

(eg. 105cm is entered as 105)

Estimate / Old Measurement H

Height is an estimate or an old measurement

Weight (kg)*

(eg. 32kg is entered as 32)

Estimate / Old Measurement W

Weight is an estimate or an old measurement

Demo Tip: The patient’s BMI will be automatically calculated for you and appear on your notification.
Enter the Height and Weight, then hit Submit to receive your notification.

Hidden

BMI Calculation (hidden – auto calculated)

Height / Weight Estimate or Old Measurement

(please add more information, such as when the height or weight was measured or if it is only a guess)

Birth information*

(please select all that apply – it is very important we know if there were significant medical issues in the first twelve months of life including prematurity, time in the Special Care Nursery (SCN) or Neonatal Intensive Care Unit (NICU), or admissions to hospital for any reason)

I had a normal birth without any issues

I was born preterm / before 37 weeks

I was born by caesarean section

I spent time in SCN or NICU

I was admitted to hospital before my 1st birthday

There were perinatal issues (eg. during pregnancy or shortly after birth)

Other / Unknown

If the caesarean section was due to a congenital anomaly, failure to progress in labour, foetal distress, or another emergency reason, please mention it below

Please provide details

Have you ever been admitted overnight to hospital or had an anaesthetic?*

Yes

Hidden

Have you ever had any anaesthetic complications or problems?(REMOVED)

Yes

Unsure

If you have ever had any reactions to or issues with receiving anaesthesia in the past, it is very important you detail this below

Please advise the approximate date, name of hospital and details of each previous procedure / hospital visit*

(if you have ever had any anaesthetic problems or anaesthetic complications (eg. severe nausea/vomiting, perioperative cardiac events etc), you must mention them here. Also, if you have ever needed a pre-med, or had another Anaesthetist suggest a pre-med might be helpful in the future, please mention this here. Providing these details can help in retrieving previous anaesthetic records meaning past problems could potentially be avoided)

Have any of your blood relatives experienced a severe reaction to an anaesthetic?*

(eg. your parents, your siblings, your parent’s siblings, your grandparents)

Yes

No / Not that I’m aware of

If yes, please provide details

Do you have any allergies?*

(especially to medications including antibiotics, latex products, foods or iodine)

Yes

No / Not that I am aware of

What are you allergic to and what is the reaction?*

Do you use regular medications, puffers or any injections?*

(this includes all syrups, tablets, puffers/inhalers, patches, sprays, eye drops, any type of injections etc.)

Yes

If yes, please detail each medication with the amount taken and how often you take it*

(please list each medication on a new line eg. medication name with active ingredient if known + amount taken + how often you take it eg. 20mg, once each morning)

Have you been unwell in the 4 weeks before your operation?*

(symptoms that could impact on the safety of an anaesthetic include fevers, rigors (shivering sweats at night), a cold or flu, chesty or wet cough, respiratory symptoms, shortness of breath, runny nose, being obviously unwell, diarrhoea, vomiting, being off their food, being home from school/daycare, not playing as they normally would, bronchiolitis, pneumonia or any other illness recently)

Yes – I have been unwell

No – I have been well and playing normally

N/A – My operation is in more than four weeks

Please provide details*

Patient Details:

ADULT DEMO ACTIVATED
You can view the Paediatric version if you enter a Date of Birth that is less than 14 years old. There are additional questions and calculations for children under 5 and also under 2 (eg. change the Date of Birth to 2/2/2024 to see the full paediatric demo)

Height (cm)*

(eg. 165cm is entered as 165)

Weight (kg)*

(eg. 70kg is entered as 70)

Demo Tip: The patient’s BMI will be automatically calculated for you and appear on your notification.
Enter the Height and Weight, then hit Submit to receive your notification.

Hidden

BMI Calculation (hidden – auto calculated)

Have you been unwell in the 4 weeks before your operation?*

(if your operation is within the next four weeks please advise if you have had a recent fever, cough, cold, flu, sore throat, respiratory symptoms, shortness of breath, runny nose, blocked nose, headache, body aches, muscle or joint pains, nausea, diarrhoea, vomiting, loss of smell/taste, loss of appetite, fatigue or any other illness recently)

Yes – I have been unwell

N/A – My operation is in more than four weeks

Please provide details*

Have you ever had an anaesthetic?*

Yes

No – This will be my first anaesthetic

If you have ever had any reactions to or issues with receiving anaesthesia in the past, it is very important you detail this below

Have you ever had any anaesthetic complications or problems?*

Yes

Unsure

Please advise the approximate date, name of hospital and details of each previous procedure / hospital visit*

(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 (eg. 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)

Have any of your blood relatives experienced a severe reaction to an anaesthetic?*

(eg. your parents, your siblings, your parent’s siblings, your grandparents, your children)

Yes

No / Not that I’m aware of

If yes, please provide details

Do you have any allergies?*

(especially to medications including antibiotics, latex products, foods or iodine)

Yes

What are you allergic to and what is the reaction?*

Do you take regular medications, puffers or any injections?*

(this includes all syrups, tablets, puffers, patches, sprays, eye drops, any type of injections etc. It is VERY important to mention if you take any weight loss injections, GLP-1 receptor agonists (eg. Saxenda, Ozempic) or any anticoagulants (eg. Aspirin, Xarelto, Eliquis, Warfarin, Clexane))

Yes

If yes, please detail each medication + amount taken + how often you take it*

(please list each medication on a new line eg. medication name with active ingredient if known + amount taken + how often you take it eg. 20mg, once each morning)
* If you would like to upload your medications list (such as a photo of the list from your GP, Webster-pak or even a photo of boxes with the prescription instructions), type UPLOAD in the text box below and the option to upload files will appear. You can then add additional medications in the text box below

TIP: Click “Save” below to send your special link to your mobile phone so you can take photos of the medication list/boxes and upload them to your form. Click “Save” again from your mobile, and you will be able to use the same special link, to finish your form here.

Upload Medications (Adult)*

You can upload files in two ways:
SELECT FILES – and locate the files you wish to upload; or
DRAG AND DROP – open your file browser and drag and drop the files you wish to send to your Anaesthetist in the box below.

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 5.

Do you smoke or vape?

No – I have never smoked or vaped

No – I previously smoked / vaped, but now do not

Yes – I smoke / vape socially only

Yes – I smoke / vape regularly

What did you smoke / vape, how often, and when was the last time you did it?

What do you smoke / vape? + How much did you smoke / vape in the last week?

Do you regularly drink alcohol?

Yes – Socially / weekends only

Yes – Often / most days

If yes, please detail what you drink and approximately how many alcoholic drinks you had in the last week

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There is normally a page break here + the option for patients to save their form

Health Information:

PAEDIATRIC DEMO ACTIVATED
Change the Date of Birth entered, to see the Adult version

Do you have any trouble with your heart or cardiovascular system, or have you ever been to a Cardiologist?*

(this could include murmurs, holes in the heart, past visits to a cardiologist, past heart surgery)

Yes

If yes, please provide details

(please make sure you include your Cardiologist’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)

Do you have shortness of breath when running slowly or playing with friends?*

Yes

Other

Do you have any trouble with your lungs or respiratory system, or have you ever seen a Respiratory/Sleep Specialist?*

(please select all that apply – this could include asthma, obstructive sleep apnoea (OSA), snoring, cystic fibrosis, bronchiolitis or pneumonia within the last 3 months or any other lung / breathing / respiratory conditions)

Yes – Asthma

Yes – Obstructive Sleep Apnoea (OSA)

Yes – Other

If yes, please select the following that apply

(multiple options can be selected)

A full canister of my reliever puffer (eg. Ventolin) lasts less than a month

I wake up during the night because I need to use my reliever puffer (eg. Ventolin)

I have required oral steroid tablets / liquid (eg. prednisone or prednisolone) to treat my asthma within the last 3 months

I have had an ‘asthma attack’

I have been admitted to hospital because of my asthma

Anti-inflammatory medicines (eg. Nurofen, Voltaren, Mobic or Celebrex) provoke or make my asthma worse

None of the above options apply to me

Important: If you have one, please bring your CPAP mask and machine (including all cables) with you into the hospital as it may be used to assist your recovery from anaesthesia

Please provide more details

(please include your Respiratory or Sleep Doctor’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)

Do you have diabetes?*

Yes

Unsure / Other

Diabetes type

Type 1

Type 2

How old when diagnosed?

How is your diabetes treated?

(select all that apply)

Insulin

Tablets / Liquids

Diet

Other

If you use insulin, at what blood glucose level (BGL) would you start to get symptoms of a 'hypo'?

(only if this is known, ie. your Anaesthetist needs to maintain your BGL above this value whilst you undergo your procedure)

Please provide details

Have you been investigated for or diagnosed with a syndrome?*

Yes

No / Not that I am aware of

Please provide more details

Do you have, or have you ever had, any of the following?

Any trouble with your heart or cardiovascular system, or have you ever been to a Cardiologist?*

(this could include hypertension / high blood pressure, chest pains, angina, heart attacks, coronary artery stents, coronary artery bypass surgery, heart rhythm problems, having a pacemaker, defibrillator, strokes or mini strokes)

Yes

If yes, please provide details

Shortness of breath climbing less than 2 flights of stairs or whilst walking for 30 minutes on flat ground?*

Yes

Other

Please provide more details

Any trouble with your lungs or respiratory system, or have you ever seen a Respiratory/Sleep Specialist?*

(please select all that apply – this could include asthma, obstructive sleep apnoea (OSA) with or without CPAP mask use, cystic fibrosis, pneumonia within the last 3 months, smoking-related problems or any other lung / breathing / respiratory conditions)

Yes – Asthma

Yes – Obstructive Sleep Apnoea (OSA)

Yes – Other lung problems

If yes, please select the following that apply

(multiple options can be selected)

A full canister of my reliever puffer (eg. Ventolin) lasts less than a month

I wake up during the night because I need to use my reliever puffer (eg. Ventolin)

I have required oral steroid tablets / liquid (eg. prednisone or prednisolone) to treat my asthma within the last 3 months

I have had an ‘asthma attack’

I have been admitted to hospital because of my asthma

Anti-inflammatory medicines (eg. Nurofen, Voltaren, Mobic or Celebrex) provoke or make my asthma worse

None of the above options apply to me

Have you been recommended to use a CPAP machine?

Yes

Do you have a CPAP machine?

Yes

Important: Please bring your CPAP mask and machine (including all cables) with you into the hospital as it may be used to assist your recovery from anaesthesia

Please provide more details

Diabetes?*

Yes

Other

Diabetes type

Type 1

Type 2

How old when diagnosed?

How is your diabetes treated?

(select all that apply)

Insulin

Tablets

Diet

Other

If you use insulin, at what blood glucose level (BGL) would you start to get symptoms of a 'hypo'?

(only if this is known, ie. your Anaesthetist needs to maintain your BGL above this value whilst you undergo your procedure)

Please provide details

Gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia, or have you had gastric surgery?*

(If you are unsure of which option to choose, please select “Yes”. Then select “Other” to enter more information. Please note: Gastric surgery is also commonly referred to as gastric band surgery, gastric bypass surgery, gastric sleeve surgery, Lap band surgery or weight loss surgery. It is VERY important to mention if you have undergone this surgery.)

Yes

If yes, please select the following that apply

(multiple options can be selected)

When bending forward or lying flat you get a burning sensation or acid rising into your mouth or throat, or you get this same sensation waking you from sleep

You previously suffered from this burning sensation or acid rising into your mouth or throat, but since commencing treatment this no longer occurs

You don’t get this acid rising sensation, but you do suffer from stomach/abdominal discomfort or burning

You previously suffered from this stomach/abdominal discomfort or burning, but since commencing treatment this no longer occurs

I’ve had gastric band / bypass / sleeve, or weight loss surgery

Other

Please provide details

Thyroid disease?*

Yes

Other

Please provide details

If yes, please select the following that apply

Your thyroid hormone levels are normal

Your last blood test was within 12 months

Your breathing becomes difficult when lying flat

You are unsure on your current thyroid disease status

Do you have an enlarged thyroid gland, otherwise called a goitre?

Yes

Your Endocrinologist's name and contact details

Neurological Condition?*

(this could include a stroke, mini-stroke, TIA, multiple sclerosis, Parkinson’s disease or epilepsy)

Yes

If yes, please provide details

(please make sure you include your Neurologist Doctor’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)

Rheumatoid arthritis, connective tissue disease or any other musculoskeletal issues?*

Yes

If yes, please provide details

(please make sure you include your Rheumatologist Doctor’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)

Kidney condition?*

Yes

If yes, please provide details

(please make sure you include your Nephrologist, Kidney or Dialysis Doctor’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)

Blood clots or excessive bleeding?*

(this could include deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia or another condition)

Yes

If yes, please provide details

(please make sure you include your Haematologist or Blood Doctor’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)

Cancer?*

Yes

If yes, please provide details including when and what treatment you received or are receiving?

(please also include your Oncologist Doctor’s name and contact details if applicable)

Is there a chance you could be pregnant?

Yes

If you are pregnant, how many weeks are you / would you be today?

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Other Health Information:

PAEDIATRIC DEMO ACTIVATED
Change the Date of Birth entered, to see the Adult version

Have you had COVID-19?*

(if you have had COVID-19 multiple times, or think you may have had it recently, please select the Yes answer based on the most recent date)

Yes – within the last 2 months

Yes – over 2 months ago

Demo Tip: If the patient has had Covid in the last 2 months, the weeks between the Covid diagnosis and the Operation Date are automatically calculated for you. This information appears on your notification.
Select Yes to COVID-19 and enter a past date, then hit Submit to receive your notification.

Please select the date of your diagnosis?*

(if you have had, or think you have had, COVID-19 multiple times, please enter the most recent date)

Hidden

DAYS between Covid+ and Operation (hidden)

Hidden

WEEKS between Covid+ and Operation (hidden)

Hidden

DAYS between Covid+ and Today (no Op date) (hidden)

Hidden

WEEKS between Covid+ and Today (no Op date) (hidden)

Please select the option that most applies to you*

I had a mild or asymptomatic COVID-19 infection

I had symptoms such as cough, shortness of breath or feeling generally unwell but did not need hospitalisation

I was hospitalised with COVID-19

I was very unwell with COVID-19 and was admitted to an intensive care unit (ICU) for treatment

Other

Other – Please advise:*

Hidden

Do you still have any symptoms? (REMOVED Sept24)

Hidden

Since COVID-19, have you been able to resume your usual exercise routine? (REMOVED Sept24)

(please provide details including outlining your current physical exercise capacity, or lingering fatigue/shortness of breath)

Have you fully recovered?*

(if you are still experiencing any symptoms, or have not been able to return to your usual sport or exercise routine, please write in the box below “No” and provide more details)

Which of the following describes your mouth and teeth?*

(please select all that apply)

Which of the following describes your mouth, teeth, and dentition?*

(please select all that apply)

Please provide more details

(is there a reason why your mouth doesn’t open fully?)

Please indicate the pain relievers or analgesics that have worked well for you previously*

Paracetamol, eg. Panadol, Dymadon

Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop

Anti-inflammatories, eg. Nurofen, Voltaren, Celebrex, Mobic

Tramadol, eg. Tramal

Tapentadol, eg. Palexia

Strong opioids, eg. OxyNorm, Endone, Targin, Sevredol

Unsure / I don’t take pain relievers

Other

Which "Other" pain relievers or analgesics have worked well for you previously?

Please indicate the pain relievers or analgesics that you must avoid or should not use*

Paracetamol, eg. Panadol, Dymadon

Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop

Anti-inflammatories, eg. Nurofen, Voltaren, Celebrex, Mobic

Tramadol, eg. Tramal

Tapentadol, eg. Palexia

Strong opioids, eg. OxyNorm, Endone, Targin, Sevredol

Other

I am not aware of any pain relievers or analgesics that I must avoid or should not use

Which "Other" pain relievers or analgesics should you avoid?

(please include as much detail as possible)

Do you have any other medical conditions not already mentioned?*

(these could include things like neurological conditions (such as cerebral palsy or epilepsy), muscle, stomach, kidney, vascular or thyroid problems, cancer, blood disorders, psychiatric / cognitive / behavioural conditions (such as autism, anxiety or developmental disorders), or anything else that could affect your health or the care you receive from your Anaesthetist)

Yes

Do you have any other medical conditions not already mentioned?*

(these could include brain, nerve, muscle, vascular problems, autism spectrum disorder, psychiatric / cognitive / behavioural conditions, difficulty lying on your back, claustrophobia, or anything else that could affect your health, your legal ability to consent or the care you receive from your Anaesthetist)

Yes

If yes, please include as much detail as possible

File Upload:

Would you like to upload any medical documents?

(if you would like to upload any medical records, summaries, test results, specialist letters, or other supporting information, you can do so here. Alternatively, you can send these to your Anaesthetist later via a message on their profile page)

TIP: Click “Save” below to send your special link to your mobile phone so you can take photos of your medical documents and upload them to your form. Click “Save” again from your mobile, and you will be able to use the same special link, to finish your form here.

Upload Files

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 12.

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There is normally a page break here + the option for patients to save their form

Other Details:

Do you have someone who can pick you up from hospital and care for you for the first 24 hours following discharge?*

Yes

Name and mobile number of your carer

(the person who will remain with you for the full 24 hours following the procedure. If there are multiple carers, please include their names, mobile numbers, and relationship to the patient)

Do you give your consent for me to contact your other doctors and access your medical records if required?*

(to provide you with the safest anaesthetic your Anaesthetist may need to contact your other doctors to obtain test results, specialist letters, or other information. This allows a better understanding of your health, and is necessary to tailor an anaesthetic to your specific needs)

Yes

Name and telephone numbers of your doctors

(if you haven’t already provided your GP and Specialist’s information earlier, please advise their name and phone number here)

Are you entitled to access Medicare rebates by the Australian Government?*

(ie. do you have a green Medicare card?)

Yes

Do you have a "My Health Record"?

Yes

Unsure

Please advise your Medicare Number

Do you have private health insurance?*

Yes

Please provide the name of your health fund and your member number

Are you currently covered for in-hospital treatment and this procedure?

(ie. have you checked with your health fund to see if this particular procedure is covered)

Yes

Unsure

NON-IFC Standard Questionnaire available
We understand that some Anaesthetists have already provided patients with an estimate. We can remove the Estimate, Payment Method (+/- Contact, Medicare, PHI) questions from your Standard Pre-Op form. To hide these questions from patients, simply ask for the “Non-IFC” Standard Questionnaire when registering with us, or by email at any time later.
Option 1 – remove Estimate, Payment Method questions only
Option 2 – remove Estimate and Payment Method questions – then advise which of the following you would like removed:
a) the “Are you entitled to access Medicare” group of questions
b) the “Do you have private health insurance?” group of questions
c) the “Would you like to be contacted” question

Disclaimer question available
The following new disclaimer consent question is also available on both IFC and non-IFC Standard questionnaires. Please email us to request this be added to your form:
“I am aware there will be a fee from my Anaesthetist. I have been advised of, or will seek, Informed Financial Consent so that I am aware of the fees to be paid. I understand that if my account should fall into arrears, I accept that I will be charged collection and/or legal costs incurred.”

Need to change more?
Alternatively, with the Premium plan, we can completely customise your questionnaire and even send patient estimate requests directly to your billing service. Anything is possible on the Premium plan – see example of Premium customisations ideas here.

Would you like an estimate of the Anaesthetic Fee pre-operatively?*

Yes

No – I am happy to proceed as is

N/A – I have already received an estimate or paid the anaesthetic fee

If yes, how would you like to receive the estimate of the Anaesthetic Fee?

(please select all that apply)

SMS/text message

Phone call

Preferred method to pay Anaesthetic Fee?*

Credit Card

Direct Deposit (eg. via an internet funds transfer)

Workers Compensation / Third Party Insurance

Defence Force account / DVA Gold Card

Other

Please advise details of payment here*

Your Anaesthetist will be sent the information submitted via this questionnaire. Depending on your answers, your Anaesthetist may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, your Anaesthetist may be satisfied with the information submitted and be ready to proceed with your anaesthetic as is.

Would you like to be contacted by your Anaesthetist prior to your procedure?*

Yes

Only if my Anaesthetist has specific issues they wish to discuss

(Optional) Please advise your Postal Address if different from your home address

(we do not need your Home Address as it will be on your patient sticker. Only your Postal Address is required here, if it is different)

Demo Tip: This second email box will only display if no email was listed on the first page

(Optional) Please advise your Email Address

(if you would like your form confirmation and reference number emailed to you, please enter your email address below)

By submitting this pre-op health questionnaire on anaestheticgroup.com.au you confirm this information can be sent to your Anaesthetist in accordance with our privacy policy, the information you have provided is true and correct to the best of your knowledge and this information can be relied upon by your Anaesthetist in making clinical decisions.

Is there anything else you would like to mention?*

Yes

If yes, please provide the details here

Hidden

Days until operation (hidden – auto calculated)

Hidden

Ignore – testing a dob was entered

Hidden

Ignore (hidden)

This field is for validation purposes and should be left unchanged.

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Each profile has an inbuilt contact form allowing patients to contact you or send you files

Your own @anaestheticgroup.com.au email address which can be used to receive emails (forwarded direct into your existing mail program (e.g gmail / yahoo / outlook etc))

Add ANZCA CPD-compliant Patient Experience Surveys & Summary Reports. We act as your Administrator. There is a $225 signup fee for all online PES forms and one Summary Report (for ANZCA CPD + includes the signed verification form). Each renewal costs only $135. This package includes all forms: Adult, Paediatric, and Pain Medicine (optional).

STANDARD

Everything you need to get started.
An affordable solution created for Anaesthetists who work a mix of Public and Private

$65 / per month

Each profile has an inbuilt contact form allowing patients to contact you or send you files

Your own @anaestheticgroup.com.au email address which can be used to receive emails (forwarded direct into your existing mail program (e.g gmail / yahoo / outlook etc)) PLUS the option for you to send emails from it too

Unlimited patient responses. Instant Notifications. Choose between an IFC or a non-IFC version of our Standard Pre Op Questionnaire – try a demo here

ANZCA CPD-compliant Patient Experience Surveys & Summary Reports. We act as your Administrator. Unlimited patient responses and Summary Reports (+ signed ANZCA CPD verification forms). It’s never been easier to complete your CPD

ANZCA CPD-compliant Pain Medicine Patient Experience Surveys & Summary Reports. Unlimited patient responses and Summary Reports (+ signed ANZCA CPD verification forms)

Link to our patient information pages directly from your profile page. There are over 20 information sheets available

Link to an online payment gateway page so patients can pay online (e.g. Stripe), and you will receive the funds directly

We contact you when local Surgeons ask us to fill their regular and adhoc lists. This is a growing component of our website and a complimentary service we offer.

We are a full service company. Any backend, coding, HTML or any changes you require we do for you. Your plan comes with unlimited changes free of charge. All changes are made by our Sydney office and usually within 48 hours

PREMIUM

Made for Anaesthetists who prefer a custom solution or who work mostly in Private

$125 / per month

Each profile has an inbuilt contact form allowing patients to contact you or send you files

Receive your own custom domain name (e.g. dryourname.com.au) Your name is on the registration of the domain name and we will maintain it for you whilst you remain a paid member – however if you ever do decide to leave us, you can take it with you

Your own domain name comes complete with matching email accounts (e.g. [email protected], [email protected], [email protected] ..) can be forwarded direct into your existing mail program(s) (e.g gmail / yahoo / outlook etc)) plus with the option for you to send emails from it too

Complete customisation (e.g. change questions, confirmation and notification messages making it entirely unique to you – examples of other members changes are here). Unlimited patient responses. Instant Notifications. Unlimited changes – The options are endless and as a full service company we handle all changes for you

ANZCA CPD-compliant Pain Medicine Patient Experience Surveys & Summary Reports. Unlimited patient responses and Summary Reports (+ signed ANZCA CPD verification forms)

Link to our patient information pages directly from your profile page. There are over 20 information sheets available

Have your own patient information documents downloadable from your profile page. These can include, for example, FAQs or post-op advice sheets, and other useful documents. This way, your patients can access the information at a time that suits them

Provide a link to an online payment gateway page so patients can pay online (e.g. Stripe), and you will receive the funds directly

We contact you first when your local Surgeons ask us to fill their regular and adhoc lists. This is a growing component of our website and a complimentary service we offer. In the allocation of lists, Premium Plan members are put forward as a priority

As a Premium member you receive your own account manager (and can call or SMS them at any time with questions or support). We are a full service company. Any backend, coding, HTML or any changes you require we do for you. Your plan comes with unlimited changes free of charge. All changes are made by our Sydney office and usually within a few hours

Please click on each inclusion above to see more information on the feature
All pricing is in $AUD and includes 10% GST. We accept Mastercard, Visa, PayPal, American Express.

Looking to join multiple Anaesthetists to a Group Plan? Contact us here

Demo – Pre-Op Health Questionnaire

Patient Details:

Operation Details:

Patient Information:

Patient Details:

Health Information:

Do you have, or have you ever had, any of the following?

Other Health Information:

File Upload:

Other Details:

Ready to Sign up Now?

FREE

A great fit for those starting out or mainly working in Public

$0 / per month

STANDARD

Everything you need to get started.
An affordable solution created for Anaesthetists who work a mix of Public and Private

$65 / per month

PREMIUM

Made for Anaesthetists who prefer a custom solution or who work mostly in Private

$125 / per month

PATIENTS

SURGEONS

ANAESTHETISTS

Patient Details:

Operation Details:

Patient Information:

Patient Details:

Health Information:

Do you have, or have you ever had, any of the following?

Other Health Information:

File Upload:

Other Details:

Ready to Sign up Now?

FREE

A great fit for those starting out or mainly working in Public

$0 / per month

STANDARD

Everything you need to get started.An affordable solution created for Anaesthetists who work a mix of Public and Private

$65 / per month

PREMIUM

Made for Anaesthetists who prefer a custom solution or who work mostly in Private

$125 / per month

PATIENTS

SURGEONS

ANAESTHETISTS

Everything you need to get started.
An affordable solution created for Anaesthetists who work a mix of Public and Private