Pre-Op Health Questionnaire Step 1 of 5 - Please complete the Patient and Operation Details below: 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 your Anaesthetist is properly prepared for your anaesthetic, please complete this pre-op health questionnaire to the best of your ability. On average, it takes 10-15 minutes to complete this questionnaire. If you are unable to complete it in one session (under 30 minutes), or 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 at the bottom of the 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 field The Anaesthetist selected is:*Patient 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*MaleFemalePhone Number(s)*Email Patient's Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age (Hidden - auto calculated)Operation 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)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, or any other illnesses recently)Yes - I have been wellNo - I have been sickN/A - My surgery is in more than two weeksPlease provide details*Have you ever had an anaesthetic?*YesNo - This will be my first anaestheticHave you ever had any anaesthetic complications or problems?*YesNoUnsureIf 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?*YesNo / Not that I'm aware ofIf 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 regular medications?*(this includes all syrups, 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 smoke?No - I have never smokedNo - I previously smoked, but now do notYes - I smoke socially onlyYes - I smoke regularlyWhat did you smoke, how often and when was the last time you smoked?What do you smoke and how much did you smoke in the last week?Do you regularly drink alcohol?NoYes - Socially / weekends onlyYes - Often / most daysIf yes, please detail what you drink and approximately how many alcoholic drinks you had in the last week Do you have, or have you ever had, any of the following?Any trouble with your heart or cardiovascular system?*(this could include hypertension / high blood pressure, chest pains, angina, heart attacks, coronary artery stents, coronary artery bypass surgery, heart rhythm problems, having a pacemaker, 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?*YesNoAny 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 - Asthma Yes - Obstructive Sleep Apnoea (OSA) Yes - Other lung problems No If yes, please select the following which apply(multiple options can be selected) A full canister of my reliever puffer (eg. Ventolin) lasts less than a month I wake up during the night because I need to use my reliever puffer (eg. Ventolin) I have required oral steroid tablets / liquid (eg. prednisone or prednisolone) to treat my asthma within the last 3 months I have had an 'asthma attack' I have been admitted to hospital because of my asthma Anti-inflammatory medicines (eg. Nurofen, Voltaren, Mobic or Celebrex) provoke or make my asthma worse None of the above options apply to me Have you been recommended to use a CPAP machine?YesNoDo you own a CPAP machine?(it is important to bring your CPAP mask with you to hospital as it may to assist your recovery from general anaesthesia)YesNoPlease provide more details(please also include your Respiratory or Sleep Doctor's name and contact details if applicable plus when you were last reviewed)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. 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?*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 or gastric sleeve surgery Thyroid 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 detailsNeurological Condition?*(this could include a stroke, mini-stroke, TIA, multiple sclerosis, Parkinson's disease or epilepsy)YesNoIf yes, please provide details (make sure you include your Neurologist Doctor's contact details if applicable)Rheumatoid arthritis?*YesNoIf yes, please provide details (make sure you include your Rheumatologist Doctor's contact details if applicable)Kidney condition?*YesNoIf 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)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?YesNoIf 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 havePlease 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 your Anaesthetist later via a message on their 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 your anaesthetist 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)YesNoAre you entitled to access Medicare rebates by the Australian Government?*(ie. do you have a green Medicare card?)YesNoDo you have a "My Health Record"?YesNoPlease advise your Medicare NumberDo 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?*YesNo - I am happy to proceed as isN/A - I have already paid the anaesthetic feeIf 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 CardDirect Deposit (eg. via an internet funds transfer)Workers Compensation / Defence Force account / DVA Gold Card / Third Party InsuranceOtherPlease advise payment details here*Your anaesthetist will be sent the information submitted via this questionnaire. Depending upon your answers, your anaesthetist may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, your anaesthetist 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 your anaesthetist prior to your procedure?*YesOnly if my anaesthetist has specific issues they wish to discussNo(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 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. Is there anything else you would like to mention?*YesNoIf yes, please provide the details hereCommentsThis field is for validation purposes and should be left unchanged.
