Pre Op Anaesthetic Assessment - Dr Izak Perold's 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 anaestheticgroup.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 Dr Perold 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 questionnaire.

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

Tips:
* To go back to a previous page please only use the “PREVIOUS” button at the bottom of the page
* You can send Dr Perold extra files later via the contact form on his profile page
* 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 the form for you to add any additional information or ask questions to Dr Perold – 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.

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.

Date of Birth*

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

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

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?)

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

Other Details:

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

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

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 Perold 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

Dr Perold will be sent the information submitted via this questionnaire. Depending upon your answers, Dr Perold may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, Dr Perold 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 Perold prior to your procedure?*

Yes

Only if Dr Perold has specific issues he wishes 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, if different, is needed here

By submitting this pre op anaesthetic assessment form 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

(Hidden) Days until operation

Hidden

Ignore (Hidden)

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

Pre Op Anaesthetic Assessment Form – Dr Izak Perold

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