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 drjayram.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 Jayram is properly prepared for your anaesthetic, please complete this questionnaire to the best of your ability.

If would like to finish this form 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.

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

Is this you?*

Yes

Your Name

Relationship to Patient

Phone Number(s)*

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 Age*

(in years - if a child, please use a decimal if desired, eg. 2years 6months = 2.5)

Operation Details:

Surgeon*

Hospital

Operation*

(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?)

Patient Details:

Height (cm)*

(eg. 165cm is entered as 165)

Weight (kg)*

(eg. 70kg is entered as 70)

Have you had any flu like symptoms within the last 3 weeks?*

(if your surgery is within the next three weeks please advise if you have had a recent cough, cold, sore throat, shortness of breath, runny nose, fatigue, muscle aches, pain, fever, loss of smell/taste or any other illness recently)

No - I have been well

Yes - I have been sick

N/A - My surgery is in more than three weeks

Please provide details*

Have you ever had an anaesthetic?*

Yes

No - This will be my first anaesthetic

Have you ever had any anaesthetic complications or problems?*

Yes

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 ever had a problem with anaesthetics?*

Yes

No / Not that I'm aware of

If yes, please provide details

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 heart problem or have had any reason to see a Cardiologist in the past?*

(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)

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. your anaesthetist 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, 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

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)

Have you ever been diagnosed with COVID-19 illness or tested positive for Coronavirus?*

Yes

Unsure

Please provide details (including when and have your symptoms resolved)

Have you ever received a COVID-19 vaccine?*

Yes - Double / Triple +

Yes - Single dose only

No - I am unvaccinated

Is there a chance you could be pregnant?

Yes

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

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 Jayram later via a message on his profile page.

File One

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