Pre-Op Health Questionnaire – Dr D’Souza "*" 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 drcarldsouza.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 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 No Your Name Relationship to Patient Phone Number*Email Please complete all of the following questions based on the patientie. when the question refers to "you" please describe the patient's health. Patient's Date of Birth*DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenAge (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)HiddenNEW - 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 No If yes, please provide detailsCan 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 No 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 No 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 No 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 No 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 No 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 No 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 No Diabetes?* Yes No 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 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 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 No 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 No Your Endocrinologist's name and contact details Kidney condition?* Yes No 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 No 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 No 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 No If yes, please provide detailsPlease 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 No 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.YesNoDocument OneFiles supported: jpg, gif, png, pdf Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 128 MB.Document TwoFiles supported: jpg, gif, png, pdf Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 128 MB.Document ThreeFiles supported: jpg, gif, png, pdf Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 128 MB.Document FourFiles supported: jpg, gif, png, pdf Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 128 MB.Document FiveFiles supported: jpg, gif, png, pdf Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 128 MB.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:Have you been overseas in the last 14 days?* Yes No Other Please provide details including a list of each country visited and transited throughDo you have a responsible adult who can collect you from hospital and stay with you for the first 24 hours after discharge?* Yes No Please note: In order to go ahead with your procedure you must have a responsible adult collect you and stay with you. Please make arrangements for this now.Name and telephone numbers of your doctors(GPs and Specialists)Do you give your consent for me to contact your other doctors if required?*(to provide you with the safest anaesthetic Dr D'Souza 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 No Do you have private health insurance?* Yes No If yes, to which health fund do you belong and what is your member number? By submitting this pre-op health questionnaire on anaestheticgroup.com.au you confirm this information can be sent to Dr D'Souza 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. Dr D'Souza will telephone you prior to your surgery to discuss any medical issues you might have and to go through the anaesthetic to be provided on the day. It will also be an ideal time to ask any questions you might have.Is there anything else you would like to mention?* Yes No If yes, please provide the details hereEmailThis field is for validation purposes and should be left unchanged.
