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 anaestheticgroup.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 Kinchington is properly prepared for your anaesthetic, please complete this pre-op health questionnaire to the best of your ability.

On average, it takes 5-10 minutes to complete this questionnaire. If you are unable to complete it in one session (or under 15 minutes), 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:
- Name of Health Fund
- 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 your Anaesthetist

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

Are you the patient?*

Yes

Your Name

Relationship to Patient

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

Gender*

Male

Female

Phone Number(s)*

(please list the best phone number to contact you on first)

Patient's Age*

(in years - if a child, please use a decimal for the months eg. 2 years 9 months = 2.9)

Patient's Date of Birth*

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)

Are you well at the moment?

(if your surgery is within the next two weeks please advise if you have had a recent cough, cold, runny nose or any other illnesses 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 been sick in the last 2 weeks?

(ie. cough, runny nose, cold or fever)

Yes - I have been sick

No - I have been well

Please provide details*

(including are you well now? Eating normally? Playing normally?)

Have you ever had an anaesthetic?

Yes

No - This will be my first anaesthetic

Please include an approximate date and details of your recent procedures

(if you have undergone a lap band (laparoscopic gastric banding) procedure it is important that you detail this operation here. If you have ever had any anaesthetic problems or anaesthetic complications 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)

Please include an approximate date and details of your recent procedures

If you have ever had any anaesthetic problems or anaesthetic complications 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 syrups, 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 regularly smoke or drink alcohol?

Yes - I regularly smoke and / or drink alcohol

No - I do not regularly smoke and I do not regularly drink alcohol

If yes, please detail how many alcoholic drinks and how much you smoke in an average week

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)

Yes

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

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

Other

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

Any breathing problems?*

(this could include asthma, bronchiotis in last 3 months, snoring, obstructive sleep apnoea, cystic fibrosis)

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

Stomach Problems*

(this could include gastro-oesophageal reflux disease (GORD))

Yes

If yes, please provide details

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

Neurological Condition?*

(this could include a stroke, mini-stroke, TIA, multiple sclerosis, Parkinson's disease or epilepsy)

Yes

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

Any brain, nerve or muscle problems?*

(this could include cerebral palsy, epilepsy, developmental delay, autism, behavioural problems)

Yes

If yes, please provide details

Do you have a syndrome?*

Yes

If yes, please provide details

Rheumatoid arthritis?*

Yes

If yes, please provide details (make sure you include your Rheumatologist Doctor's contact details if applicable)

Kidney problems?*

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?*

(this could include deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia or another condition)

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

If you are pregnant, how many weeks are you / would you be today?

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

Braces

Caps, crowns, or veneers

Implant(s)

Bridge(s)

Partial upper dentures

Partial lower dentures

Full upper dentures

Full lower dentures

Other

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

(please select all that apply)

Your own teeth +/- fillings only

No teeth

Loose tooth or teeth

Chipped tooth or teeth

Braces

Caps, crowns, or veneers

Other

Please advise the "Other" teeth or dentition you have

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

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

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

Which "Other" pain relievers or analgesics should you avoid?

(please include as much detail as possible)

Hidden

TEST - Please indicate the pain relievers or analgesics that have worked well for you previously and those you must 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 Kinchington later via a message on his profile page.

Document One

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