Pre-Op Health Questionnaire – Dr Pedersen "*" 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 drpedersen.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 Pedersen is properly prepared for your anaesthetic, please complete this questionnaire to the best of your ability. On average, it takes 5-15 minutes to complete this 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 your Anaesthetist Tips: 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. If you 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. * Denotes a required fieldPatient Details:Patient's Name* First Last Are you the patient?* Yes No Your NameRelationship to PatientPlease 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 Non-Binary Phone Number(s)*Email I give authority for my invoice (if applicable) to be sent via email Patient's Date of Birth*DDDD12345678910111213141516171819202122232425262728293031MMMM123456789101112YYYYYYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This field is hidden when viewing the formAge (Hidden - auto calculated)Operation Details:Surgeon*HospitalOperation*(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?)Will you be coming in as a private or public patient?* Private patient Public patient I am unsure Patient Details:Height (cm)*(eg. 165cm is entered as 165)Weight (kg)*(eg. 70kg is entered as 70)This field is hidden when viewing the formNEW - BMI Calculation (Hidden)Have you had a general anaesthetic before?* Yes No 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)Have any blood relatives ever had any problems with anaesthetics in the past?* Yes No, not to the best of my knowledge 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 medications?*(this includes all inhalers, 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 itDo you drink alcohol? Yes No Other Approximately how much do you drink per week?(for example how many drinks have you had in the past 7 days) 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 two weeks?*(significant symptoms which could impact on the safety of an anaesthetic include fevers, rigors (shivering sweats at night), chesty moist productive coughs, shortness of breath, or being obviously unwell. Note - do not select 'Yes' for a simple cold or runny nose) Yes No If yes, please provide detailsAny cold or flu symptoms in the last six weeks?*(including a simple cold, runny nose, wet or dry cough, fever or just feeling generally unwell) Yes No Unsure Please provide detailsWhat were your symptoms? (e.g headache, congested, sputum production, cough etc)How do you feel now? Do you still have a cold or flu? How long since your cold or flu finished?Have you had a COVID test in the past 6 weeks?* Yes No Please advise COVID test date(s) and result(s)Do you have Asthma?* Yes No Other Asthma 'Other' detailsHave you ever had an 'asthma attack'?* Yes No How often have you had an ‘asthma attack' and when most recently?*Have you ever been to hospital because of asthma?* Yes No When was the most recent time and have you ever been you admitted overnight to hospital because of asthma?*Do you live in a house where people smoke inside? Yes No Have you ever smoked cigarettes or other?* Yes No Do you currently smoke?* Yes No How much did you smoke in the last week?*How much did you smoke in the past?When did you give up?Have you smoked at all since then? Yes No Only a few Other 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 Please provide further detail on what you can manageDo you ever snore? Yes No Not sure Asthma 'Other' detailsDo you have known Obstructive sleep apnoea (OSA)? Yes No Other Asthma 'Other' detailsAny trouble with your lungs or respiratory system?*(this could include cystic fibrosis or smoking-related problems) Yes No Do you use a CPAP mask?* Yes No Please bring your CPAP mask with you to hospital Please provide details (please include your Respiratory or Sleep Doctor's name and contact details if applicable)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 Pedersen 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 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 Other (I'd like to add more comments) Please provide any comments belowThyroid 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 detailsKidney 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)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)Rheumatoid arthritis (RA)?* Yes No If yes, please provide details (make sure you include your Rheumatologist or Treating Doctor's contact details if applicable)Do you have a history of blood clots or excessive bleeding or any condition that may increase your risk of these?*(eg. 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)Is there a chance you could be pregnant? Yes No 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 Please advise the "other" pain relievers or analgesics that you must avoid or should not use This field is hidden when viewing the formHIDDEN - Upload medical information(please feel free to upload any medical reports, test results, Specialist letters or supporting information)Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 128 MB.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 Pedersen later via a message on her 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.Do you have any music preference (to play during your Caesarean section)? Yes No Please advise your music preferenceWe can play your preferred music via Spotify if you have a public playlist or favourite artist etc Please let me know if you have a preferred song or artist you’d like to hear in theatre just before your anaesthetic:Coronavirus (COVID-19)Please select your activities based on the past 14 days(please tick all boxes below which apply - multiple options can be selected) I have travelled to another state or city I have been to an area identified as a COVID-19 hotspot / exposure site I have been to a large event (of over 50 people) I have been in close contact with a confirmed (or presumed) case of COVID-19 None of the above apply to me Please provide more information on each item above you selected:(make sure you include date and location)Have you been asked to isolate / quarantine?(please select the box which most applies to you) Yes - I am currently under orders to isolate / quarantine Yes - In the last 14 to 30 days I have been told to isolate / quarantine Yes - Over 30 days ago, I was told to isolate / quarantine I have never been asked to isolate / quarantine Please provide more information(make sure you include location details causing isolation, and when your isolation will end / or did end) Please note: If you have a COVID-19 test in the 3 days before your operation, please bring the test result with you Other Details:Do you have someone to collect you from hospital and who can help you for the first 24 hours after discharge?* Yes No Name 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 Pedersen 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 What are the risks of an Anaesthetic?*Australia is the safest country in the world to undergo an anaesthetic. Nonetheless, every anaesthetic involves some risk. There are minor complications that do not affect long-term quality of life but can be unpleasant, and there are major complications that occur very rarely but do impact on a patient's long-term functional capacity and quality of life. I will discuss the relevant risks with you when we talk, and I would encourage you to ask me any specific questions that you may have. * Minor complications – could almost be called expected side-effects in some patients. These include a sore nose or throat from the breathing tube, post-operative nausea and vomiting, and some discomfort or pain * Moderate complications occur with less frequency, say one chance in hundreds of operations, but are more troublesome. These can include teeth or lip damage either from the breathing tube being inserted or removed, or possibly due to actions of the surgeon. Also, a significant nosebleed is possible if a nasal tube is used * Severe complications occur very rarely but impact on a patient's long-term functional capacity or quality of life. The risk of one of these major complications is about the same as the risk of having a car crash. These can include severe drug reactions such as anaphylaxis, awareness under anaesthesia, heart attacks, strokes, eye damage with permanent loss of vision, aspiration with significant respiratory compromise, and spinal cord or peripheral nerve injuries leading to weakness, numbness, neuropathic pain, bowel or bladder dysfunction, or complete permanent paraplegia. The risk of dying due to the anaesthetic is incredibly small I have read and accept the risksAre you entitled to access Medicare rebates by the Australian Government?*(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 an email quote or estimate of the Anaesthetic Fee pre-operatively?*(your gap invoice will arrive approximately 3-4 weeks after surgery. For some procedures prepayment is required.) Yes - Please send an estimate No - I am happy to proceed as is N/A - I have already received a quote / not applicable Would you like an email quote or estimate of the Anaesthetic Fee pre-operatively?* Yes - Please send an estimate No - I am happy to proceed as is N/A - I have already received a quote / not applicable N/A - Endoscopy / Colonoscopy (No Additional Fee) Dr Pedersen will receive all the information submitted via this questionnaire. Depending upon your answers, Dr Pedersen may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, Dr Pedersen 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 Pedersen prior to your procedure?* Yes Only if Dr Pedersen has specific issues she wishes to discuss No (Optional) Please advise your Postal Address if different from your home address(we do not need your Home Address as it will be on your patient sticker - only your Postal Address, if different, is needed here)By submitting this pre-op health questionnaire on anaestheticgroup.com.au you confirm this information can be sent to Dr Pedersen 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 Dr Pedersen in making clinical decisions.Is there anything else you would like to mention?*(if you have any extra notes, concerns or queries) Yes No If yes, please provide detailsCommentsThis field is for validation purposes and should be left unchanged.
