Pre-Op Anaesthetic Assessment Form

"*" 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 drallchurch.com.au from your desktop or laptop

The hospital will commonly have you complete a similar form prior to your admission for their own records – this is not provided to your Anaesthetist. To ensure Dr Allchurch is properly prepared for your anaesthetic, please complete this pre-op anaesthetic assessment form to the best of your ability.

This form should take approximately 15 minutes to complete. If you are unable to complete this form in one session, have an unstable internet connection, or would like to finish it on another device, you can save your responses and return to the form at any time if you click the “Save Your Form to Complete Later” button at the bottom of the assessment form.

To enable you to complete your form as quickly as possible, please have on hand:
– Details of your current medications, weight (kg) & height (cm)
– Contact details of your usual Doctors (GP & Specialists)
– A scanned PDF or JPG of any results, medications or letters you wish to send Dr Allchurch

Tips:
* To go back to a previous page please only use the “PREVIOUS” button at the bottom of the page
* You can send Dr Allchurch extra files later via the contact form on her profile page at drallchurch.com.au
* When you click “Save Your Form to Complete Later” you will receive a unique link that can be clicked, copied or emailed. If you save your form, your entered data won’t be lost if you leave your device. The link can even be used on a different device (eg. for taking pictures or checking dates, heights, or weights).
* Some of the fields are mandatory and are marked with an asterisk (*)
* There is room at the very end of this pre-op anaesthetic assessment form for you to add any additional information or ask questions to Dr Allchurch – click YES to “Is there anything else you would like to mention?” for the box to appear.

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.

Date of Birth*

Hidden

Age (Hidden – auto calculated)

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

Gender*

Female

Male

Other

What were you assigned at birth?

Female

Male

What do you identify with now?

Phone Number(s)*

Please check your email address. You entered “.con” but normally it’s “.com“
If you would like to receive a confirmation of this form, you will need to enter a valid email address above.

Operation Details:

Surgeon*

Hospital

Operation*

(the procedure being performed)

Date of Operation

Why are you having this operation?

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

Pre-Op Anaesthetic Assessment Form – Dr Allchurch

Patient Details:

Operation Details:

Patient Details:

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

File Upload

Other Details:

PATIENTS

SURGEONS

ANAESTHETISTS