Pre Anaesthetic Assessment – Dr Namy Mahadnac "*" indicates required fields Step 1 of 5 - Please complete the Patient and Operation Details below: 0% EmailThis field is for validation purposes and should be left unchanged.Please note: This form can be completed from ANY deviceIf you would rather complete this on a bigger screen, please click 'Save Your Form' below or visit drnamy.com.au from your desktop or laptopYou 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 Dr Namy Mahadnac is properly prepared for your anaesthetic, please complete this pre anaesthetic assessment form to the best of your ability. This form 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 5 minutes of inactivity for security and privacy reasons), or if your internet connection is unstable. You can complete your pre anaesthetic assessment form faster if you have the following ready: – Details of your current medications, weight (kg) & height (cm) – Information about your health conditions and previous procedures – 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 Dr Mahadnac 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 Dr Mahadnac later via the contact form on his profile page (drnamy.com.au) * To provide additional information or ask questions to Dr Mahadnac, 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 pre anaesthetic assessment.Patient Details:Patient's Name* First Last Are you the patient?* Yes No Your NameRelationship to PatientPlease complete all of the following questions based on the patientie. when the question refers to "you" please describe the patient's health. Gender* Female Male Other What were you assigned at birth? Female Male What do you identify with now?Preferred name(how would you like to be addressed)Date of Birth*(select your date of birth using the calendar icon or enter it as dd/mm/yyyy eg. 01/05/1981) DD slash MM slash YYYY 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 ownThis field is hidden when viewing the formAge (hidden - auto calculated)Phone Number(s)*Email 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*HospitalOperation*(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) DD slash MM slash YYYY This field is hidden when viewing the formAge in Months (hidden - auto calculated for <2y)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 Patient Information: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 This field is hidden when viewing the formBMI 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 belowPlease provide detailsDo 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 No 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 Have you had a respiratory infection or cold in the last 4 weeks?* Yes No Please provide details*Patient Details:Height (cm)*(eg. 165cm is entered as 165)Weight (kg)*(eg. 70kg is entered as 70)This field is hidden when viewing the formBMI 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) No Yes - I have been unwell N/A - My operation is in more than four weeks Have you had a respiratory infection or cold in the last 4 weeks?* Yes No Please provide details*(include as much information as you can, such as when symptoms started, what you experienced, duration, and whether you sought medical treatment)Do you have any allergies?*(especially to medications including antibiotics, latex products, foods or iodine) Yes No 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. Ozempic, Mounjaro, Wegovy, Saxenda, Trulicity etc) or any anticoagulants (eg. Eliquis, Xarelto, Aspirin, Warfarin etc)) Yes No Do you take any GLP-1 receptor agonists or weight loss medications?*(these medications, commonly prescribed for diabetes or weight loss, can deliberately delay gastric emptying and significantly affect how anaesthesia works in your body. Common brand names include Ozempic, Mounjaro, Wegovy, Saxenda, and Trulicity etc. It is VERY important for your safety that Dr Mahadnac is aware if you take them. In the medication box below, please make sure you enter the medication name, dosage, and date of last dose) Yes No If you are taking a GLP-1 receptor agonist, please read the special "Patient information sheet (GLP-1)" fasting instructions that will be emailed to you carefully, as these may differ from other fasting instructions you may have received. You should receive this email the moment you submit this form, or another copy can be found on my website (drnamy.com.au) or the Australian and New Zealand College of Anaesthetists (ANZCA) website.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 belowTIP: 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 Dr Mahadnac in the box below. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 4 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? No 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 Health Information: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 No 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 No 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 No 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 anaesthesiaHow is your condition being managed?(please note your current treatments so I can understand how severe the condition is and how it is being managed)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 No 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. Dr Mahadnac needs to maintain your BGL above this value whilst you undergo your procedure)Please provide detailsHave you been investigated for or diagnosed with a syndrome?* Yes No / Not that I am aware of Please provide more detailsDo 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 No 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)Shortness of breath climbing less than 2 flights of stairs or whilst walking for 30 minutes on flat ground?* Yes No Other Please provide more detailsAny 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 No 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 For how many years have you had a diagnosis of OSA?How severe is it? (AHI number on sleep study)Have you been recommended to use a CPAP machine? Yes No Do you have a CPAP machine? Yes No What is your CPAP pressure setting?(your pressure setting - a number usually between 4 and 20, which you can find on your CPAP machine)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 anaesthesiaHow is your condition being managed?(please note your current treatments so I can understand how severe the condition is and how it is being managed)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), whether there is ongoing follow-up and an approximate date of your last visit)Diabetes?* Yes No 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. Dr Mahadnac needs to maintain your BGL above this value whilst you undergo your procedure)Please provide detailsGastro-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 No 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 detailsDo you have any other medical conditions that need or have needed treatment?*(multiple options can be selected - please select any other medical conditions that require treatment, have required treatment in the past or that you see a doctor for) Thyroid disease Neurological condition (eg. stroke, MS, Parkinson's, epilepsy etc) Rheumatoid arthritis, connective tissue disease or any other musculoskeletal issues Kidney condition Blood clots or excessive bleeding (eg. DVT, PE, haemophilia etc) Cancer Other None of the above Thyroid disease: Please select the following that apply(multiple options can be selected) 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 Other Do you have an enlarged thyroid gland, otherwise called a goitre? Yes No Please provide more details(please make sure you include your Endocrinologist 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)Neurological Condition: 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: 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: 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: 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: 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)Other: Please provide details(please make sure you include your Specialist 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) Anaesthesia Questions:Have you ever had an anaesthetic?* Yes No - This will be my first anaesthetic Have you ever been admitted overnight to hospital or had an anaesthetic?* Yes No 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 No 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)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, your children) Yes No / Not that I'm aware of If yes, please provide detailsPlease indicate the pain relievers or analgesics that have worked well for you previously*(these could include ones you take at home or have had during any procedures) 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)Other Health Information:Is there a chance you could be pregnant? Yes No If you are pregnant, how many weeks are you / would you be today?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 Dr Mahadnac) Yes No 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 Dr Mahadnac) Yes No If yes, please include as much detail as possibleFile Upload:Would you like to upload any medical documents?(if you would like to upload any medical records, summary of medications / pictures of the actual boxes with the prescription visible, test results, specialist letters, or other supporting information, you can do so here. Alternatively, you can send these to Dr Mahadnac later via a message on his profile page - drnamy.com.au)NoYesTIP: 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 FilesYou 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 Dr Mahadnac in the box below. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 4 MB, Max. files: 5. 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 No 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 Dr Mahadnac 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 No 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)(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)(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) This field is hidden when viewing the formPlease read and confirm 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.Dr Namy Mahadnac will be sent the information submitted via this questionnaire. Depending on your answers, Dr Mahadnac may decide to contact you to obtain more information, or simply to discuss particular aspects of the operation, anaesthetic or pre-operative medication management. Alternatively, Dr Mahadnac may be satisfied with the information submitted and be ready to proceed with your anaesthetic as is. Is there anything else you would like to mention?* Yes No If yes, please provide the details hereBy 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. This field is hidden when viewing the formDays until operation (hidden - auto calculated)This field is hidden when viewing the formIgnore (hidden GLP1 Yes)This field is hidden when viewing the formIgnore (hidden Anaesthetic Problems Yes)
