Pre-Op Health Questionnaire – Dr Doogan "*" indicates required fields Step 1 of 5 - Please complete the Patient and Operation Details below: 0% Please note: This form can be completed from ANY deviceIf 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 laptopThe 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 Doogan is properly prepared for your anaesthetic, please complete this pre-op health questionnaire 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 questionnaire as quickly as possible, please have on hand: - Your health care cards (Medicare card, private fund card etc) - Contact details of your usual Doctors (GP & Specialists) - Details of your current medications, weight & height - A scanned PDF or JPG of any results or letters you wish to send your Anaesthetist Tips: * To go back to a previous page please only use the "PREVIOUS" button at the bottom of the 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 (*) 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)Phone Number(s)*Email Ooops! 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. Patient's Date of Birth* DD slash MM slash YYYY This field is hidden when viewing the formAge (Hidden - auto calculated)Operation Details:Surgeon*HospitalOperation*(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?)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.Confirm Baby* I confirm my date of birth above is correct and this form is being filled in for a baby 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 form(Hidden) BMI CalculationAre you well at the moment?*(if your surgery is within the next two 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 well No - I have been sick N/A - My surgery is in more than two weeks Please provide details*Have you had a cough or cold in the last 2 weeks?*(please select Yes if your child has had a cough or cold in the last 2 weeks) Yes No Do they have a fever currently?Are they eating and drinking normally?Are they playing as normal?Have you ever had an anaesthetic?* Yes No - This will be my first anaesthetic Have you ever had any anaesthetic complications or problems?* Yes No 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 include an approximate date and details of your recent procedures*(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 had a serious, life-threatening 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 detailsDo you have any allergies?*(especially to medications including antibiotics, latex products, foods or iodine) Yes No If 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.) Yes No Can you swallow tablets?(is your child able to swallow tablets on their own) 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 your Anaesthetist 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 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)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?The knowledge from international research suggests that not smoking for a time prior (48hrs) to your operation results in significant change in the intraoperative and post-operative course of lung complications.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 In planning my anaesthetic, I need to know accurately your alcohol intakeIf yes, please detail what you drink and approximately how many alcoholic drinks you had in the last week Do you have, or have you ever had, any of the following?Asthma? Yes No Unsure 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 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)Any other health issues?(this could include diabetes or any other issues affecting their health. Please be as detailed as possible)With regards to teeth - are there any loose teeth at the moment? Yes - Loose tooth or teeth No Is your child particularly anxious about having an operation or anaesthetic? Yes No Unsure Please be reassured that Dr Doogan can give your child a medication before the operation to help your child to remain calmDo 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?*(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 No 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 No Do you own a CPAP machine?(it is important to bring your CPAP mask with you to hospital as it may to assist your recovery from general anaesthesia) Yes No 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)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 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 Doogan needs to maintain your BGL above this value whilst you undergo your procedure)Please provide detailsThis field is hidden when viewing the formDiabetic on Tablets (warning)Some tablets for diabetes need to be stopped 3 days before your operation. These include canagliflozin, dapagliflozin, empagliflozin, Jardiance, forxiga. Please cease these medications 3 days before your operation and do not re-start them until you are eating and drinking normally.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 No 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 gastric band / bypass / sleeve, or weight loss surgery Other Please provide detailsThyroid disease?* Yes No Other OtherPlease provide detailsIf 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 No Your Endocrinologist's name and contact detailsNeurological Condition?*(this could include a stroke, mini-stroke, TIA, multiple sclerosis, Parkinson's disease or epilepsy) Yes No 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 No Unsure 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 No 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 No 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)Is there a chance you could be pregnant? Yes No If you are pregnant, how many weeks are you / would you be today?Which of the following describes your mouth, teeth, and dentition?*(please select all that apply) I am unable to open my mouth fully I have my own teeth only (with or without fillings) Loose tooth or teeth Chipped tooth or teeth Braces Caps, crowns, or veneers Implant(s) Bridge(s) Partial upper dentures Partial lower dentures Full upper dentures Full lower dentures Other Please provide more details*(is there a reason why your mouth doesn’t open fully? or which "other" teeth or dentition do you have?) Do you have any facial hair (eg. beard, moustache)? Yes No Facial hair can affect the fit of oxygen and anaesthetic masks. If you are having a general anaesthetic, it may improve your safety if your facial hair is shaved before your procedure. Please contact Dr Doogan if you would like more information.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 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 Doogan) Yes No If yes, please include as much detail as possibleWould you like to upload any medical documents?Please feel free to upload any medical reports, test results, Specialist letters or supporting information. Alternatively you can securely send these to Dr Doogan later via a message on her profile page.YesNoUpload Files Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 12 MB, Max. files: 6. Once you click Next, please allow a few moments for your files to upload. If you are concerned the page has frozen, please click Save Your Form to Complete Later below to ensure your previous entries are saved. Other Details:Are you currently a hospital inpatient? Yes No Please specify which hospital and wardDo you have someone to collect you from hospital and who can help you for the first 24 hours after discharge?* Yes No Dr Doogan will be sent the information submitted via this questionnaire. Depending upon your answers, Dr Doogan may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, Dr Doogan may be satisfied with the information submitted and be ready to proceed with your anaesthetic as is.(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) Is there anything else you would like to mention?Anaesthetic Risks*Anaesthesia today is very safe. Advances in equipment, monitoring and drug therapy as well as Australian standard of practice has all contributed to this safety. Some surgery or procedures carry a higher risk. Some patients have increased risks because of their pre-existing medical conditions. I have read and understand the below risks 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. This field is hidden when viewing the form(Hidden) Days until operationThis field is hidden when viewing the form(Hidden) BMI 30+This field is hidden when viewing the formGLP-1 Medication?NameThis field is for validation purposes and should be left unchanged.
