Pre-Op Health Questionnaire – Dr Pedersen Step 1 of 5 0% 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 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 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 fieldPatient Details:Patient's Name* First Last Are you the patient?*YesNoYour 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*MaleFemaleNon-BinaryPhone Number(s)*Email I give authority for my invoice (if applicable) to be sent via email Patient's Age*(in years - if a child, please use a decimal if desired, eg. 2years 6months = 2.6)Patient's Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Operation Details:Surgeon*HospitalOperation*(the procedure being performed)Date of Operation Date Format: 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)NEW - BMI Calculation (Hidden)Have you had a general anaesthetic before?*YesNoPlease 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?*YesNo, not to the best of my knowledgeIf yes, please provide detailsDo you have any allergies?*(especially to medications including antibiotics, latex products, foods or iodine)YesNoIf 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.) YesNoIf yes, please detail each medication with the amount taken and how often you take itDo you drink alcohol?YesNoApproximately 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)YesNoIf 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)YesNoIf 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)YesNoUnsurePlease 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?Asthma?*YesNoHave you ever had an 'asthma attack'?*YesNoHow often have you had an ‘asthma attack' and when most recently?*Have you ever been to hospital because of asthma?*YesNoWhen 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?YesNoHave you ever smoked cigarettes or other?*YesNoDo you currently smoke?*YesNoHow 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?YesNoOnly a fewAny 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)YesNoIf 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?*YesNoDo you ever snore?YesNoNot sureAny trouble with your lungs or respiratory system?*(this could include obstructive sleep apnoea (OSA) with or without CPAP mask use, or smoking-related problems)YesNoDo you have known Obstructive sleep apnoea (OSA)?YesNoDo you use a CPAP mask?*YesNoPlease bring your CPAP mask with you to hospital as it may to assist your recovery from general anaesthesia.If yes, please provide details (please include your Respiratory or Sleep Doctor's name and contact details if applicable)Diabetes?*YesNoHow 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?*YesNoIf 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?*YesNoIf 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?YesNoYour Endocrinologist's name and contact detailsKidney condition?*YesNoIf 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)YesNoIf yes, please provide details (make sure you include your Neurologist's contact details if applicable)Rheumatoid arthritis (RA)?*YesNoIf 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)YesNoIf 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?YesNoWith 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 HIDDEN - 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.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.Document TwoFiles supported: jpg, gif, png, pdf Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.Document ThreeFiles supported: jpg, gif, png, pdf Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.Document FourFiles supported: jpg, gif, png, pdf Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.Document FiveFiles supported: jpg, gif, png, pdf Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx.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. Other Details:Do you have someone to collect you from hospital and who can help you for the first 24 hours after discharge?*YesNoName and telephone numbers 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)YesNoWhat 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?)YesNoDo you have private health insurance?*YesNoIf yes, to which health fund do you belong and what is your member number?Are you currently covered for in-hospital treatment?YesNoUnsureWould you like a quote or estimate of the Anaesthetic Fee pre-operatively?*Yes - Please send a quoteNo - I am happy to proceed as isN/A - I have already received a quote / I am a public patientWould you like a quote or estimate of the Anaesthetic Fee pre-operatively?*Yes - Please send a quoteNo - I am happy to proceed as isN/A - I have already received a quote / I am a public patientN/A - Endoscopy / Colonoscopy (No Additional Fee)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 Phone call Preferred method to pay Anaesthetic Fee?*Credit Card (MasterCard or Visa with a 1.1% processing fee)Direct Deposit / Internet TransferWorkers Compensation or Defence Force accountOtherPlease advise your 'Other' preferred payment method:*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?*YesOnly if Dr Pedersen has specific issues she wishes to discussNo(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)Is there anything else you would like to mention?*YesNoIf yes, please provide detailsBy 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.CommentsThis field is for validation purposes and should be left unchanged.
