Pre-Op Health Questionnaire

"*" indicates required fields

Step 1 of 5 - Please complete the Patient and Operation Details below:

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 To Complete Later' below or visit dressop.com.au from your desktop or laptop

The hospital will commonly have you complete a similar questionnaire prior to your 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 questionnaire to the best of your ability.

On average, it takes 10 minutes to complete this questionnaire. If you are unable to complete it or would like to finish it on another device, you can save your answers and return at any time by clicking the “Save Your Form to Complete Later” button at the bottom of the questionnaire.

Tip: If you wish to navigate back to a previous page at any stage, please only use the “PREVIOUS” button at the bottom of the page.

* Denotes a required field

Patient Details:

Patient's Name*

First Last

Gender*

Male

Female

Are you the patient?*

Yes

Your Name

Relationship to Patient

Phone Number(s)*

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

Date of Birth*

DD slash MM slash YYYY

Hidden

Age (Hidden - auto calculated)

Operation Details:

Surgeon*

Hospital

Operation*

(the procedure being performed)

Date of Operation

DD slash MM slash YYYY

Why are you having this operation?

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

Patient Details:

Height (cm)*

(eg. 165cm is entered as 165)

Weight (kg)*

(eg. 70kg is entered as 70)

Hidden

(Hidden) BMI Calculation

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)

Yes - I have been well

No - I have been sick

N/A - My surgery is in more than two weeks

Please provide details*

Have you or any blood relatives ever had any problems with anaesthetics in the past?*

Yes

If yes, please provide details

Details of previous anaesthetics

(if you can remember when and in what hospitals you previously underwent an anaesthetic, providing these details can help in retrieving previous anaesthetic records meaning past problems could potentially be avoided)

Do you have any allergies?*

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

Yes

If yes, what are you allergic to and what is the reaction?

Do you take regular medications?*

(this includes all tablets, puffers, patches, sprays, injections, eye drops etc.)

Yes

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

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.

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.)

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

Do you take regular non-prescribed medications?

(this includes all herbs and vitamins like Gingko, Echinacea etc.)

Yes

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

Please cease all non-prescribed medications for at least a week prior to your operation due to the effect they have on bleeding

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

Any heart problem or have had any reason to see a Cardiologist in the past?

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

Yes

If yes, please provide details (make sure you include your Cardiologist's name and contact details if applicable)

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?*

(this could include asthma, obstructive sleep apnoea (OSA) with or without CPAP mask use, cystic fibrosis or smoking-related problems)

Yes - Asthma

Yes - Obstructive Sleep Apnoea (OSA)

Yes - Other lung problems

If yes, please select the following which 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: Bring your CPAP mask and machine with you to hospital as it may assist your recovery from general anaesthesia

Please provide more details

(please also include your Respiratory or Sleep Doctor's name and contact details if applicable plus when you were last reviewed)

Have you ever been diagnosed with COVID-19 or tested positive for Coronavirus?

Yes

Unsure

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)

DD slash MM slash YYYY

Hidden

(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)

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:*

Do you still have any symptoms?*

Since COVID-19, have you been able to resume your usual exercise routine?*

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

Diabetes?*

Yes

How old when diagnosed?

How is your diabetes treated?

(select all that apply)

Insulin

Tablets

Diet

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)

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.

Gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia?*

Yes

If yes, please select the following which 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 a gastric band or gastric sleeve surgery

Other

Please provide details

Thyroid disease?*

Yes

If yes, please select the following which 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 (make sure you include your Neurologist Doctor's contact details if applicable)

Rheumatoid arthritis, osteoarthritis or any other musculoskeletal issues?*

Yes

If yes, please provide details (make sure you include your Rheumatologist Doctor's contact details if applicable)

Kidney condition?*

Yes

If yes, please provide details (make sure you include your Nephrologist, Kidney or Dialysis Doctor's name and contact details if applicable)

Blood clots or excessive bleeding?*

(eg. deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia, and others)

Yes

If yes, please provide details (make sure you include your Haematologist or Blood Doctor's name and contact details if applicable)

Liver disease?*

(this could include fatty liver or cirrhosis)

Yes

If yes, please provide details (make sure you include your Hepatologist, Gastroenterologist or Liver Doctor’s name and contact details if applicable)

Infectious disease?*

(eg. have you ever been diagnosed or treated for an infectious disease such as Hepatitis, HIV or another infection?)

Yes

If yes, please provide details

(please include the type of infection, your treatment plus the details of your specialist and when you last saw them)

Is there a chance you could be pregnant?

Yes

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

With regards to your teeth or dentition - what do you have?*

(please select all that apply)

Your own teeth only (with or without fillings)

Loose tooth or teeth

Chipped tooth or teeth

Braces

Wire retainer

Caps, crowns, or veneers

Implant(s)

Bridge(s)

Partial upper dentures

Partial lower dentures

Full upper dentures

Full lower dentures

Other

Please advise the "Other" teeth or dentition you have

Do you have any limitation with opening your mouth fully?

Yes

Please advise more details

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

Paracetamol, eg. Panadol

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

Tramadol, eg. Tramal

Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop

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

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

Tramadol, eg. Tramal

Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop

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)

What type of physical activity are you able to do?

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

Do you smoke?

No - I have never smoked

No - I previously smoked, but now do not

Yes - I smoke socially only

Yes - I smoke regularly

What did you smoke, how often and when was the last time you smoked?

What do you smoke and how much did you smoke 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

File Upload

Would you like to upload any medical documents?

If you would like to upload any medical records, 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.

Upload Files

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: 8 MB, Max. files: 6.

Coronavirus (COVID-19)

Please select your activities based on the past 14 days

(please tick all boxes below which apply - multiple options can be selected)

I have travelled to another country, state or city

I have been to a large event (of over 50 people)

I have been in close contact with a confirmed (or presumed) case of COVID-19

I have a household member with COVID-19 or a respiratory illness

None of the above apply to me

Please provide more information on each item above you selected:

(make sure you include date and location)

Have you been asked to isolate / quarantine?

(please select the option which most applies to you)

Yes - I am currently under orders to isolate / quarantine

Yes - In the last 7 to 30 days I have been told to isolate / quarantine

Yes - Over 30 days ago, I was told to isolate / quarantine

I have not been asked to isolate / quarantine

Please provide more information

(make sure you include location details causing isolation, and when your isolation will end / or did end)

Have you received a COVID-19 vaccine?

Yes - Triple +

Yes - Double dose only

Yes - Single dose only

No - I am unvaccinated

Please note: If you have a COVID-19 test in the 3 days before your operation, please bring the test result with you

Other Details

Are you currently a hospital inpatient?

Yes

Please specify which hospital and ward

Do you have someone to collect you from hospital and who can help you for the first 24 hours after discharge?*

Yes

Name and telephone numbers of your doctors

(GPs and Specialists)

Do you give your consent for me to contact your other doctors 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 better understanding of your health, meaning your anaesthetic can be individualised appropriately)

Yes

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 + Identifier

Do you have private health insurance?

(multiple options can be selected - if you have Hospital AND Extras Cover, please select Yes to each option)

Yes - Hospital Cover

Yes - Extras Cover

No - I do not have private health insurance

Unsure

If yes, to which health fund do you belong and what is your member number?

If you haven’t already been contacted by our staff, would you like an estimate of the Anaesthetic Fee pre-operatively?*

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

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

(please select all that apply)

SMS/text message

Phone call

Preferred method to pay Anaesthetic Fee?*

Credit Card

Cash

Direct Deposit (eg. via an internet funds transfer)

Workers Compensation or Defence Force account

DVA Gold Card

We will also email you a copy of these details
Direct Deposit Details:
Commonwealth Bank
BSB: 062500
Account: 10376708
Name: Dr Essop

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

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

Yes

Only if Dr Essop has specific issues he wishes to discuss

By submitting this form you confirm the information provided is true and correct to the best of your knowledge and 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 details

Hidden

(Hidden) Days until operation

Hidden

Ignore (Hidden)

Comments

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

Pre-Op Health Questionnaire – Dr Essop

Patient Details:

Operation Details:

Patient Details:

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

File Upload

Coronavirus (COVID-19)

Other Details

PATIENTS

SURGEONS

ANAESTHETISTS