Pre Anaesthetic Assessment Form – Dr Gilchrist "*" 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 drgilchrist.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 Gilchrist is properly prepared for your anaesthetic, please complete this pre 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 form. To enable you to complete your form as quickly as possible, please have on hand: – Your health care cards (Medicare card, private health 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 to Dr Gilchrist Tips: * To go back to a previous page please only use the “PREVIOUS” button at the bottom of the page * You can send Dr Gilchrist extra files later via the contact form on his profile page (drgilchrist.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 the questionnaire for you to add any additional information or ask questions to Dr Gilchrist – 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 No Your Name Relationship to Patient Phone Number(s)*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* DD slash MM slash YYYY HiddenAge in Years (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 ownGender* Female Male Other Gender* Female Male What were you assigned at birth? Female Male What do you identify with now? Operation Details:Surgeon* Hospital Operation*(the procedure being performed) Date of Operation DD slash MM slash YYYY HiddenAge in Months on Operation Date (Hidden – auto calculated)Why are you having this operation?(what symptoms or diagnosis made you to decide to undergo this procedure?) The Date of Birth entered on the previous page indicates that the patient is a baby.If the patient is not a baby, please go back (click “Previous” below) and update the Date of Birth entered. Please confirm the patient is a baby* Yes, the patient is a baby Patient Details:We understand that children’s height and weight change regularly. Please enter your child’s last known height and weight (in cm and kg). Please check the box below if the information provided was an estimate or an old measurement.Height (cm)*(eg. 165cm is entered as 165)Estimate / Old Measurement H Height is an estimate or an old measurement Weight (kg)*(eg. 70kg is entered as 70)Estimate / Old Measurement W Weight is an estimate or an old measurement HiddenBMI Calculation (Hidden)Are you well at the moment?*(if your surgery is within the next three weeks please advise if you have had a recent significant respiratory tract infection, acute medical problem, etc.) Yes – I have been well No – I have been sick N/A – my procedure is in more than three weeks Please provide detailsHave 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, please ensure you detail this belowPlease include the approximate dates, hospitals and details of your previous procedures Please list the details of your past surgical procedures, in particular if you have undergone a lap band (laparoscopic gastric banding) or a gastric sleeve procedure. If you have ever had any anaesthetic problems or anaesthetic complications (e.g. 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 avoidedHave any of your blood relatives had a serious, life-threatening reaction to an anaesthetic?* Yes No / Not that I am 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. It is very important to mention if you take any weight loss injections) Yes No If yes, please detail each medication with the amount taken and how often you take itIf you have a medication list from your GP please upload it below. Alternatively, please detail each medication (or any other medications you take) with the strength taken and how often you take itUpload Medication FileYou can upload your file in two ways: SELECT FILE – and locate the file you wish to upload; or DRAG AND DROP – open your file browser and drag and drop the file you wish to send to your Anaesthetist in the box below. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 8 MB, Max. files: 2. Can you swallow tablets?(is your child able to swallow tablets on their own) Yes No Do you smoke? No – I have never smoked No – I previously smoked, but now do not Yes – I smoke socially only Yes – I smoke regularly What do you smoke and how much did you smoke in the last week? Do you regularly drink alcohol? No Yes – Socially / weekends only Yes – Often / most days If 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?Any significant medical issues in the first twelve months of life?*(this can include prematurity, time in the Special Care Nursery (SCN) or Neonatal Intensive Care Unit (NICU), or admissions to hospital for any reason) Yes No If yes, please provide detailsAny significant respiratory tract infections within the last three weeks?*(significant symptoms which could impact on the safety of an anaesthetic include fevers, rigors (shivering sweats at night), chesty or wet cough, shortness of breath, being obviously unwell, being off their food, being home from school/daycare or not playing as they normally would. Note – do not select ‘Yes’ for a simple cold or runny nose) Yes No N/A – my procedure is in more than three weeks If yes, please provide detailsAny heart or cardiovascular problems, or have you had any reason to see a Cardiologist in the past?*(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) Yes No If yes, please provide details (make sure you include your Cardiologist's name and contact details if applicable)Any trouble with your heart or cardiovascular system?*(this could include murmurs, holes in the heart, past visits to a cardiologist, past heart surgery) Yes No If yes, please provide details (make sure you include the Cardiologist or Paediatrician’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 Other Shortness of breath when playing or running around with friends* Yes No Other Please provide more details Obstructive sleep apnoea (OSA)?* Yes No If yes, were you recommended to use a CPAP machine? Yes No Do you have a CPAP machine? Yes No Important: Please bring your CPAP mask and machine with you to hospital as it may assist your recovery from anaesthesia.Failure to bring it in may lead to your procedure being postponed.Please provide details of your Respiratory or Sleep Doctor's name and contact details if applicable, and also when you had a sleep study or were last reviewedAsthma?* Yes 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 (eg. prednisone or prednisolone) to treat my asthma within the last 3 months I have previously been admitted to Intensive Care 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 Any other trouble with your lungs or respiratory system?* Yes No Any other trouble with your lungs or respiratory system?*(this could include bronchiolitis or pneumonia within the last 3 months, cystic fibrosis or any other lung / breathing / respiratory conditions) Yes No If yes, please provide details (make sure you include your Respiratory Doctor's name and contact details if applicable)Have you had COVID-19?*(if you have had COVID-19 multiple times, or think you may have had it recently, please select the Yes answer based on the most recent date) Yes – within the last 2 months Yes – over 2 months ago No Please select the date of your diagnosis?*(if you have had, or think you have had, COVID-19 multiple times, please enter the most recent date) DD slash MM slash YYYY Hidden(Hidden) DAYS between Covid+ and OperationHidden(Hidden) WEEKS between Covid+ and OperationHidden(Hidden) DAYS between Covid+ and Today (no Op date)Hidden(Hidden) WEEKS between Covid+ and Today (no Op date)Have you fully recovered and been able to resume your usual exercise routine?* Yes No Please select the option that most applies to you* I had a mild or asymptomatic COVID-19 infection I had symptoms such as cough, shortness of breath or feeling generally unwell but did not need hospitalisation I was hospitalised with COVID-19 I was very unwell with COVID-19 and was admitted to an intensive care unit (ICU) for treatment Other Other – Please advise:* Do you still have any symptoms?* Since COVID-19, have you been able to resume your usual exercise routine?*(please provide details including outlining your current physical exercise capacity, or lingering fatigue/shortness of breath) Have you been vaccinated against COVID-19?* 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 Gilchrist 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, or have you had gastric band or gastric sleeve 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 a gastric band or gastric sleeve surgery Other (I’d like to add more comments) Stomach Problems?*(this could include gastro-oesophageal reflux disease (GORD)) Yes No Please provide detailsThyroid disease?* Yes No Other Other*Please provide details If yes, please select the following which apply(multiple options can be selected) 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 Neurological condition?*(this could include stroke, mini-stroke, TIAs, multiple sclerosis, Parkinson’s disease, epilepsy, migraines, muscular dystrophy, myasthenia gravis, myotonic dystrophy) Yes No If yes, please provide details (make sure you include your Neurologist's contact details if applicable)Arthritis?*(please select all that apply) No Yes – Rheumatoid Arthritis Yes – Osteoarthritis Other Please provide details (make sure you include your Rheumatologist or treating Doctor's contact details if applicable)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)Liver condition?* Yes No If yes, please provide details (make sure you include your Hepatologist, Gastroenterologist or Liver Doctor's name and contact details if applicable)Do you have a syndrome?* Yes No / Not that I know of If yes, please provide detailsDo you have a history of blood clots or excessive bleeding or any condition that may increase your risk of these?*(e.g. deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia, thalassaemia, von Willebrand 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)Have you had cancer treatment? Yes No In which part of your body was cancer identified? Did you have Chemotherapy or Radiation Therapy?(please select all that apply) Yes – Chemotherapy Yes – Radiation Therapy No What was the type of Chemotherapy? Please provide details (make sure you include your Cancer Specialist or Oncologist’s name and contact details if applicable)Do you live with any transmissible viral infections?(this could include Hepatitis, HIV or another infection) Yes No Other Please provide more detailsIs there a chance you could be pregnant?* Yes No If you are pregnant, how many weeks are you / would you be today? Any other medical conditions not already mentioned?*(these could include brain, nerve, muscle problems, autism spectrum disorder, cerebral palsy, epilepsy, developmental delays, behavioural problems, psychiatric / cognitive conditions, arthritis, thyroid issues, kidney or liver problems, cancer, blood clots or excessive bleeding, transmissible viral infections, or anything else that could affect your health or the care you receive from your Anaesthetist) Yes No If yes, please provide detailsWhich 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 Wire retainer Caps, crowns, or veneers Implant(s) Bridge(s) Partial upper dentures Partial lower dentures Full upper dentures Full lower dentures Which of the following describes your mouth and teeth?*(please select all that apply) I am unable to open my mouth fully I have my own teeth only Loose tooth or teeth Chipped tooth or teeth Braces Wire retainer Caps, crowns, or veneers No teeth Please provide more details(is there a reason why your mouth doesn’t open fully?) Please indicate the pain relievers or analgesics that have worked well for you previously* Paracetamol, eg. Panadol, Dymadon Anti-inflammatories, eg. Nurofen, Voltaren, Celebrex, Mobic Tramadol, eg. Tramal Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop Strong opioids, eg. OxyNorm, Endone, Targin, Sevredol, Palexia 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 Anti-inflammatories, eg. Nurofen, Voltaren, Celebrex, Mobic Tramadol, eg. Tramal Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop Strong opioids, eg. OxyNorm, Endone, Targin, Sevredol, Palexia I am not aware of any pain relievers or analgesics that I must avoid or should not use Other Which "Other" pain relievers or analgesics should you avoid? 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 Gilchrist later via a message on his profile page.YesNoUpload FilesYou can upload files in two ways: SELECT FILES – and locate the files you wish to upload; or DRAG AND DROP – open your file browser and drag and drop the files you wish to send to your Anaesthetist in the box below. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 8 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” to ensure your previous entries are saved. Other Details:Do you have a responsible adult who can collect you from hospital and stay with you for the first 24 hours after discharge?* Yes – I have someone to collect and also help me for 24 hours No Where paediatric patients are discharged after any form of short stay procedure, it is recommended that transit back to their normal residence is by car. There should be two responsible adults in the vehicle; one to supervise the paediatric patient and the other the dedicated driver. For the 24 hours after the anaesthetic, we advise children should avoid activities where coordination is required. This may include, but not limited to, avoiding climbing, bike riding, soccer, swimming, horse riding, gymnastics, etc.Please note: In order for your procedure to go ahead you must have a responsible adult collect you and also stay with you for the 24 hours after your anaesthetic. Please make arrangements for this now.For the 24 hours after the anaesthetic, you must not perform any potentially dangerous tasks, such as cooking, driving, signing important documents or undertake activities where coordination is required.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, or to access your medical records if required?*(to provide you with the safest anaesthetic Dr Gilchrist may need to contact your other doctors / hospitals 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 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 Are you entitled to access Medicare rebates by the Australian Government for elective procedures?*(ie. do you have a green Medicare card?) 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? Are you currently covered for in-hospital treatment? Yes No Unsure Would you like a quote or estimate of the Anaesthetic Fee pre-operatively?* Yes No – I am happy to proceed as is If yes, how would you like to receive the quote or estimate of the Anaesthetic Fee?(please select all that apply) SMS/text message Email Preferred method to pay Anaesthetic Fee?* Credit Card (MasterCard or Visa) Workers Compensation / Defence Force account / Third Party Insurance Claim Other Please provide details – provide as much detail as possible(eg. for a Workers Compensation claim include insurance company, claim number, employer and date of injury, and contact details for your case manager)Please provide details* Dr Gilchrist will be sent the information submitted via this questionnaire. Depending upon your answers, Dr Gilchrist may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, Dr Gilchrist may be satisfied with the information submitted and be ready to proceed with your anaesthetic as is. Would you like to receive a phone call from Dr Gilchrist prior to your procedure?* Yes Only if Dr Gilchrist has specific issues he wishes to discuss No 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. You also acknowledge Dr Gilchrist may print this information out at the hospital on your day of surgery, and add it to your hospital record.Is there anything else you would like to mention?* Yes No If yes, please provide details*Hidden(Hidden) Days until operationHiddenIgnore (Hidden) PhoneThis field is for validation purposes and should be left unchanged.
