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 drcarldsouza.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 D'Souza is properly prepared for your anaesthetic, please complete this pre-op health questionnaire to the best of your ability.

On average, it takes 10-15 minutes to complete this questionnaire. If you are unable to complete it in one session (under 30 minutes), 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.

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
- A scanned PDF or JPG of any results or letters you wish to send Dr D'Souza

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*

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

Patient's Date of Birth*

Hidden

Age (Hidden - auto calculated)

Operation Details:

Surgeon*

Hospital

Operation*

(the procedure being performed)

Date of Operation

(please move on to the next question if the date is yet to be finalised)

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

NEW - BMI Calculation (Hidden from user)

Are you currently sick or suffering from a cough, runny nose, sore throat, fevers, cold, fatigue, muscle aches, pain or headache?*

Yes - I have been sick

No - I have been well

Other

Please provide details*

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

Yes

If yes, please provide details

Can you list the operations you have had previously, the year they were performed and the hospital they were performed at?

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

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

Any trouble with your heart or cardiovascular system?*

(this could include high blood pressure, 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

Any trouble with your lungs or respiratory system?*

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

Yes

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

Have you had a Covid-19 infection? If so when?*

Do you suffer from any neurological condition?*

(such as stroke, mini stoke, TIA, multiple sclerosis, Parkinson's disease, epilepsy, etc.)

Yes

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

Do you currently smoke tobacco or cigarettes?*

Yes

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. Dr D'Souza needs to maintain your BGL above this value whilst you undergo your procedure)

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

You wake from sleep with this burning or acid sensation

You previously suffered from this burning sensation or acid rising into your mouth or throat, but since commencing treatment this no longer occurs

You have never suffered from this burning sensation or acid rising into your mouth or throat

You suffer from stomach/abdominal discomfort or burning

You previously suffered from stomach/abdominal discomfort or burning, but since commencing treatment this no longer occurs

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

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)

Is there a chance you could be pregnant?

Yes

How many weeks into the pregnancy are you?*

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

(please select all that apply)

Your own teeth +/- fillings only

Loose tooth or teeth

Chipped tooth or teeth

Caps, crowns, or veneers

Implant(s)

Bridge(s)

Partial upper dentures

Partial lower dentures

Full upper dentures

Full lower dentures

Do you have any limitation with opening your mouth fully?

Yes

If yes, please provide 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

None of the above

Other

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

Any other health issues you wish to mention?*

Yes

If yes, please provide details

Would 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 D'Souza later via a message on his profile page.

Document One

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