Pre-Op Health Questionnaire – Dr McMahon "*" indicates required fields Step 1 of 7 - 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 drchrismcmahon.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 McMahon is properly prepared for your anaesthetic, please complete this pre-op health questionnaire to the best of your ability. On average, it takes 10-20 minutes to complete this questionnaire. If you are unable to complete it in one session (or under 30 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: - Your Medicare number - 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 McMahon Dr McMahon prints this information out at the hospital on your day of surgery and adds it to your hospital record. He does not retain your information. 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 No Your Name Relationship to Patient Please complete all of the following questions based on the patientie. when the question refers to "you" please describe the patient's health. Gender* Male Female Phone Number(s)*Email HiddenOLD 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*DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenAge (Hidden - auto calculated)Please check - if you are a parent filling in the form for your child, please make sure you use YOUR CHILD'S date of birth and not your ownMedicare Number and Identifier* 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)HiddenBMI Calculation (Hidden)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, sore throat, fatigue, muscle aches, pain, fever or any other illness recently) Yes - I have been well No - I have been sick N/A - My surgery is in more than two weeks Already mentioned on previous page Please provide details*Have you ever had an anaesthetic?* Yes No - This will be my first anaesthetic Please list your operations / procedures (include those from many years ago) and include the hospital and year*Did you have any anaesthetic problems or anaesthetic complications?*Please ensure you mention any anaesthetic problems or anaesthetic complications. 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 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?*What type of physical activity are you able to do? Light intensity - eg. walking Moderate intensity - eg. swimming, tennis Vigorous intensity - eg. jogging, aerobics None - I am not able to do any exercise Please do not exercise the morning of your operation as you are likely to be fasting and will subsequently be dehydrated.Have you had cancer treatment?* Yes No In which part of your body was cancer identified? Did you have Chemotherapy? Yes No What was the type of Chemotherapy? Did you have Radiation Therapy? Yes No Did you experience reduced exercise capacity, difficulty breathing once you started Chemotherapy? Yes No Did you get reviewed by a specialist, have an echocardiogram (ultrasound of the heart), or lung tests? Yes No Other Who was the specialist? Where were the tests done? Have these symptoms resolved? Yes No Other Please check with your surgeon if you are required to cease medications which increase bleeding eg. (not limited to) Clopidogrel, apixaban, warfarin. Do you take regular prescribed medications?*(this includes all syrups, tablets, puffers, patches, sprays, injections, eye drops etc.) Yes No Please list your medications including the dose and details of when you usually take it (this is important as it enables correct administration times to be prescribed for admission)*Please include the mg/mcg amount of your tablets so that prescribing may be accurate (list each medication on a new line) GLP1 Receptor Agonists (eg. Saxenda, Ozempic) deliberately delay gastric emptying. Please withhold the dose in the week prior to surgery.What medication has your surgeon advised you to cease?*Please also include details on when your surgeon has advised you to take the last dose of that medication.Please note that you may receive advice from me that requires you to not take other medication the day of or day prior to your operation. Do you take regular non-prescribed medications?*(this includes all herbs and vitamins like Gingko, Echinacea etc.) Yes No If yes, please detail each with the amount taken and how often you take itPlease cease all non-prescribed medications for at least a week prior to your operation due to the effect they have on bleedingHave you used a “cough syrup” medication in the past 12 months (pholcodine containing) commonly an over the counter purchase at a pharmacy? Yes No Unsure Have you had blood tests done recently? Yes No Unsure Please select who the blood test company was North Coast Pathology NSW Health Pathology QML Queensland Health Pathology Sullivan and Nicolaides Other Blood test company name Does anyone smoke in the home/car environment? Yes No Children should not be exposed to smoke for at least 48 hours prior and for 3 days after the procedure. There is correlation for children exposed to smoke to be at greater risk of respiratory complications during and after the procedure.Do you regularly drink alcohol? Yes - I regularly drink alcohol No - I do not regularly drink alcohol If yes, please detail how many alcoholic drinks you consume in an average weekDo you smoke or vape?(this could include things like cigarettes, E-cigarettes, marijuana etc.) Yes - I regularly smoke / vape No - I do not regularly smoke / vape If yes, please included details like when and what do you smoke / vape? The knowledge from international research suggests that not smoking / vaping for a time prior (48hrs) to your operation results in significant change in the intraoperative and post-operative course of lung complications.Do you use recreational substances? Yes - I use recreational substances No - I have not used recreational substances If yes, please included details like when and what did you last use?It is important to avoid recreational substances, at least in the week prior to your operationHave you received a COVID-19 vaccine?* Yes - Double / Triple + Yes - Single dose only No - I am unvaccinated When was your last dose/booster?(eg. month / year) Do you have a copy of your child's immunisation record?*You can access your child's immunisation statement using either your Medicare online account through myGov or via the Medicare mobile app.If you do not have a copy available please tick No, then note the last immunisation date below and bring a printed copy/screen capture to view on the day Yes - I will upload it here No - I will bring a printed copy/screen capture to view on the day Please upload a copy of the child’s immunisation record* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, jpeg, jpg, jpeg, Max. file size: 128 MB, Max. files: 2. Please note details of the last immunisation received*Please also bring a printed copy/screen capture of the immunisation statement to view on the day Do you have, or have you ever had, any of the following?Any trouble with your heart, blood vessels or cardiovascular system?*(this relates to issues being treated now or in the past and 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. Multiple options can be selected) No Yes - Coronary (heart) stent Yes - Cardiac surgery Yes - Heart Valve issues Yes - Leg artery stents/bypass Yes - Other Issues Please provide detailsYour Cardiologist's name and contact details Shortness of breath climbing less than 2 flights of stairs or whilst walking for 30 minutes on flat ground?* Yes No Other Please provide details Any trouble with your lungs or respiratory system?*(this could include asthma, obstructive sleep apnoea (OSA) with or without CPAP mask use, cystic fibrosis or smoking-related problems) Yes No How is this managed?*(please select all which apply) I see a specialist (or have in the past 5 years) Managed by my GP Your specialist's name and contact details* Please provide details of your lung / respiratory problems hereDiabetes?* 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 McMahon 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, 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 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 Neurological Condition?*(this could include a stroke, mini-stroke, TIA, multiple sclerosis, Parkinson's disease, surgery on brain (tumour, bleeding, aneurysm) or epilepsy) Yes No If yes, please provide details (make sure you include the contact details of your Neurologist and also your Neurosurgeon if applicable)Any autoimmune disease?*(eg. such conditions include, but not limited to, Rheumatoid, skin conditions, bowel conditions, myasthenia gravis, Lupus) Yes No If yes, how does it affect you? Please provide details (make sure you include your Rheumatologist Doctor's contact details if applicable)Kidney condition?* Yes No How is this managed?*(please select all which apply) I see a specialist (or have in the past 5 years) Managed by my GP Your specialist's name and contact details(please make sure you include your Nephrologist, Kidney or Dialysis Doctor's name and contact details if applicable)Please provide any other details of your kidney condition hereBleeding / blood clot issues or inherited blood conditions?*(this could include deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia, excessive bleeding or another condition) Yes No / Not that I'm aware of If yes, please provide details (make sure you include your Haematologist or Blood Doctor's name and contact details if applicable)Have you had a diagnosis of COVID-19?* Yes No Unsure Please provide details (including dates)*If you have previously been diagnosed or had symptoms consistent with COVID-19, please check the option that applies to you* 1. I had a mild or asymptomatic infection. 2. I had symptoms such as cough, shortness of breath or feeling generally unwell but did not need hospitalisation. 3. I was hospitalised with COVID-19 OR I have diabetes OR I have an illness or am on medication that can affect my immune system. 4. I was very unwell with COVID-19 and was admitted to an intensive care unit for treatment. Since COVID-19, have you been able to resume your usual exercise routine?(please provide details) Please outline your current physical exercise capacity, or lingering fatigue/shortness of breath Are any members of your household currently suffering from or have recently experienced COVID-19 or a respiratory illness?* Yes No Unsure Your surgery is important and the aim is to minimise adverse events. This may require optimising the timing of your surgery. This is a complex decision which requires the consideration of disease/illness urgency and is best made through open and timely discussion with you, your surgeon and myself. For this reason please ensure your surgeon is aware of your COVID status, thus we will be able to discuss your case. The standing recommendation is for preoperative immunisation to meet the Australian immunisation advice against SARS-COV-2 to occur at least a week prior to surgery.Do you live with any transmissible viral infections?(this could include Hepatitis, HIV or another infection) Yes No Other Please provide details including your specialist and timing of recent consultDo you feel like you may have concerns with, or have you experienced/been given a diagnosis relating to your mental health? Yes No Can you please elaborate on the diagnosis?Eg. Depression, anxiety, Bipolar disorder, Personality disorder, Schizophrenia, Trauma/Grief reaction, Post natal depression, PTSD, Obsessive compulsive disorder Can you please outline measures you take to manage your mental health?Please outline concerning features which may exacerbate/lead to a deterioration in your mental healthEg. triggering sounds/words/events (NB this is particularly helpful in the critical care health setting where there can be patients of all ages, and necessary supportive breathing measures applied to maintain your oxygen levels)Have you been prescribed/tried medications which didn’t improve your mental health?Please list any medications which didn’t improve your mental healthHave you ever received or been recommended any talk-based therapy such as counselling, CBT, other forms of mental health treatment or been referred to a psychiatrist? Are there any boundaries or situations that we should be aware of? Are you (the patient) considered neurodiverse?Eg. ADHD, ADD, Autistic Spectrum Disorder Yes No Unsure Please provide the details hereIs there a chance you could be pregnant? Yes No 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 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) 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 McMahon later via a message on his profile page.YesNoFile Drop files here or Select files Accepted file types: jpg, gif, png, pdf, jpeg, jpg, jpeg, Max. file size: 128 MB, Max. files: 6. Other Details:Please provide the name and contact number of the person collecting you and supporting you in the first 24hrs after discharge?* For the 24 hours after your anaesthetic, we advise that you do not drive, sign important documents or undertake activities where coordination is required.Please confirm that you will not drive for 24 hours after surgery* Yes - I will not drive for 24 hours 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, swimming, horse riding, gymnastics, etc.Name and telephone numbers of your doctors(GPs and Specialists)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 McMahon 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 Please confirm the following:Respiratory* I have not recently had respiratory symptoms which are concerning for COVID-19 Mask Wearing* I will follow the QLD Health Chief Health Officer directives for isolation and mask wearing Support* I will have someone supporting me for the first 24 hours after discharge Dr McMahon will be sent the information submitted in this questionnaire. Discussion pertaining to billing and cost of anaesthesia services are managed through Southport Anaesthetic Specialists. Please ensure you have your health fund details and medicare details on hand when calling - (07) 5532 3667. If your surgery is complex in nature or you have health concerns which require multiple medications or visits to the specialist in the last 6 months, the practice secretary may advise you that they will get back to you after Dr McMahon has discussed your case with your surgeon.(Optional) Please advise your Postal Address if different from your home addressWe do not need your Home Address as it will be on your patient sticker - only your Postal Address, if different, is needed here Anaesthetic Risks* I have read and understand the below risksAnaesthesia 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. Hidden(Hidden) Risk Image Shown to Patients 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 McMahon may print this information out at the hospital on your day of surgery, and add it to your hospital record. He does not retain your information. Is there anything else you would like to mention?* Yes No If yes, please provide the details hereHiddenGLP1 Medication? EmailThis field is for validation purposes and should be left unchanged.
