Pre-Op Health Questionnaire "*" 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’ below or visit anaestheticgroup.com.au from your desktop or laptopYou will often be asked to complete a similar questionnaire by the hospital before 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. This questionnaire should take approximately 18 minutes to complete. We strongly recommend you click the “Save Your Form” button at the bottom of every page whenever you need to step away to check information (this form is designed to timeout after inactivity for security and privacy reasons), or if your internet connection is unstable. You can complete your questionnaire faster if you have the following ready: – Details of your current medications, weight (kg) & height (cm) – Information about your health conditions and previous procedures – Your health care cards (Medicare card, private health fund etc) – Contact details of your usual Doctors (GP & Specialists) – A scanned PDF or JPG of any results, medications or letters you wish to send your Anaesthetist Tips: * To return to a previous page, only click the “PREVIOUS” button * Some fields are mandatory and marked with an asterisk (*) * When you click “Save Your Form“, your entered data will not be lost if you leave your device. You will also see a unique link that can be clicked, copied or emailed. The link can also be used on a different device (eg. for taking pictures from your phone or checking dates, heights, or weights). * You can send extra files to your Anaesthetist later via the contact form on their profile page * To provide additional information or ask questions to your Anaesthetist, click YES to the final question “Is there anything else you would like to mention?”. 🔒 This is a secure form. Once you submit this form, it is immediately sent to your Anaesthetist and for added security Anaesthetic Group does not store your completed questionnaire.STOP! PLEASE DO NOT FILL IN THIS FORM. Please click the Pre-Op form link only on your Anaesthetist’s page(or visit anaestheticgroup.com.au to search for your Anaesthetist) to complete their form. If you see this warning and fill in this form it will not be sent to your Anaesthetist.This form will only reach your Anaesthetist when you click the link on their page. The Anaesthetist selected is:* 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* Female Male Other What were you assigned at birth? Female Male What do you identify with now? Phone Number(s)*Email Please check your email address – You entered “.con” but normally it’s “.com“ To receive confirmation of your submission, you must enter a valid email address. (However, if your email address really does contain a “.con” inside it, please disregard this message).Date of Birth*(select your date of birth using the calendar icon or enter it as dd/mm/yyyy eg. 01/05/1981) DD slash MM slash YYYY In case you are a parent filling in the form for your child, please make sure you enter your child’s date of birth and not your ownHiddenAge (Hidden – auto calculated)Operation Details:Surgeon* Hospital Operation*(the procedure being performed) Date of Operation(select the operation date using the calendar icon or enter it as dd/mm/yyyy eg. 01/12/2024) DD slash MM slash YYYY Why are you having this operation?(what symptoms or diagnosis made you decide to undergo this procedure?)Stop!! You have entered the wrong Date of BIRTH above. The age we calculated for you is “0” years old. Please scroll up and correct the “Date of Birth” entered.However, if this form is for a baby, please scroll up and fix the second question, as you answered it incorrectly.Or, please tick the box below to confirm the date of birth is correct* I confirm my date of birth above is correct and this form is being filled in for a baby Patient Details:We understand that children’s height and weight change regularly. Please enter your child’s last known height and weight (in cm and kg). Please check the box below if the information provided was an estimate or an old measurement.Height (cm)*(eg. 165cm is entered as 165)Estimate / Old Measurement H Height is an estimate or an old measurement Weight (kg)*(eg. 70kg is entered as 70)Estimate / Old Measurement W Weight is an estimate or an old measurement Height / Weight Estimate or Old Measurement(please add more information, such as when the height or weight was measured or if it is only a guess) Have you been unwell in the 4 weeks before your operation?*(if your operation is within the next four weeks please advise if you have had a recent fever, cough, cold, flu, sore throat, respiratory symptoms, shortness of breath, runny nose, blocked nose, headache, body aches, muscle or joint pains, nausea, diarrhoea, vomiting, loss of smell/taste, loss of appetite, fatigue or any other illness recently) No Yes – I have been unwell N/A – My operation is in more than four weeks Please provide details*Have you ever had an anaesthetic?* Yes No – This will be my first anaesthetic Have you ever had any anaesthetic complications or problems?* Yes No Unsure If 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 and/or major 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 experienced a severe reaction to an anaesthetic?*(eg. your parents, your siblings, your parent’s siblings, your grandparents, your children) 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?*Do you take regular medications or any injections?*(this includes all syrups, tablets, puffers, patches, sprays, eye drops, any type of injections etc. It is very important to mention if you take any weight loss injections) Yes No If yes, please detail each medication with the amount taken and how often you take it*(please list each medication on a new line. eg. medication name – amount taken – daily / weekly / when was your last dose)Do you smoke or vape? No – I have never smoked or vaped No – I previously smoked / vaped, but now do not Yes – I smoke / vape socially only Yes – I smoke / vape regularly What did you smoke / vape, how often, and when was the last time you did it?What do you smoke / vape? + How much did you smoke / vape in the last week?Do you regularly drink alcohol? No Yes – Socially / weekends only Yes – Often / most days If 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, or have you ever been to a Cardiologist?*(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) 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 Other Please provide more 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 – 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? Yes No Do you have a CPAP machine? Yes No Important: Please bring your CPAP mask and machine (including all cables) with you into the hospital as it may be used to assist your recovery from anaesthesiaPlease provide more details(please also include your Respiratory or Sleep Doctor’s name and contact details if applicable plus when you were last reviewed)Have you had COVID-19?*(if you have had COVID-19 multiple times, or think you may have had it recently, please select the Yes answer based on the most recent date) Yes – within the last 2 months Yes – over 2 months ago No Please select the date of your diagnosis?*(if you have had, or think you have had, COVID-19 multiple times, please enter the most recent date) DD slash MM slash YYYY Hidden(Hidden) DAYS between Covid+ and OperationHidden(Hidden) WEEKS between Covid+ and OperationHidden(Hidden) DAYS between Covid+ and Today (no Op date)Hidden(Hidden) WEEKS between Covid+ and Today (no Op date)Please select the option that most applies to you* I had a mild or asymptomatic COVID-19 infection I had symptoms such as cough, shortness of breath or feeling generally unwell but did not need hospitalisation I was hospitalised with COVID-19 I was very unwell with COVID-19 and was admitted to an intensive care unit (ICU) for treatment Other Other – Please advise:* Do you still have any symptoms?* Since COVID-19, have you been able to resume your usual exercise routine?*(please provide details including outlining your current physical exercise capacity, or lingering fatigue/shortness of breath) Have you fully recovered?*If you are still experiencing any symptoms, or have not been able to return to your usual exercise routine, please write in the box below “No” and provide more details. Diabetes?* Yes No How old when diagnosed? How is your diabetes treated?(select all that apply) Insulin Tablets Diet Other 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) Please provide details Gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia, or have you had gastric surgery?*(If you are unsure of which option to choose, please select “Yes”. Then select “Other” to enter more information. Please note: Gastric surgery is also commonly referred to as gastric band surgery, gastric bypass surgery, gastric sleeve surgery, Lap band surgery or weight loss surgery. It is very important to mention if you have undergone this 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 gastric band / bypass / sleeve, or weight loss surgery Other Please provide details Thyroid disease?* Yes No Other OtherPlease provide details 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 or epilepsy) Yes No If yes, please provide details (make sure you include your Neurologist Doctor's contact details if applicable)Rheumatoid arthritis, connective tissue disease or any other musculoskeletal issues?* Yes No If yes, please provide details (make sure you include your Rheumatologist Doctor's contact details if applicable)Kidney 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)Blood clots or excessive bleeding?*(this could include deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia or another condition) Yes No If yes, please provide details (make sure you include your Haematologist or Blood Doctor's name and contact details if applicable)Cancer?* Yes No If yes, please provide details including when and what treatment you received or are receiving?(please also include your Oncologist Doctor’s name and contact details if applicable)Is 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 only (with or without fillings) Loose tooth or teeth Chipped tooth or teeth Braces Wire retainer 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, Palexia Unsure / I don’t take pain relievers 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, Palexia 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)Do you have any other medical conditions not already mentioned?*(these could include brain, nerve, muscle, vascular problems, autism spectrum disorder, psychiatric / cognitive / behavioural conditions, difficulty lying on your back, claustrophobia, or anything else that could affect your health, your legal ability to consent or the care you receive from your Anaesthetist) Yes No If yes, please include as much detail as possibleFile UploadWould you like to upload any medical documents?If you would like to upload any medical records, test results, specialist letters, or other supporting information, you can do so here. Alternatively, you can send these to your Anaesthetist later via a message on their profile page.NoYesUpload FilesYou can upload files in two ways: SELECT FILES – and locate the files you wish to upload; or DRAG AND DROP – open your file browser and drag and drop the files you wish to send to your Anaesthetist in the box below. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 10 MB, Max. files: 8. 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 and telephone numbers of your doctors(if you haven’t already provided your GP and Specialist’s information earlier, please advise their name and phone number here)Do you give your consent for me to contact your other doctors and access your medical records 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) Yes No Are you entitled to access Medicare rebates by the Australian Government?*(ie. do you have a green Medicare card?) Yes No Do you have a "My Health Record"? Yes No Unsure Please advise your Medicare Number 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 and this procedure?(ie. have you checked with your health fund to see if this particular procedure is covered) Yes No Unsure Would you like an estimate of the Anaesthetic Fee pre-operatively?* Yes No – I am happy to proceed as is N/A – I have already received an estimate or paid the anaesthetic fee If yes, how would you like to receive the estimate of the Anaesthetic Fee?(please select all that apply) SMS/text message Email Phone call Preferred method to pay Anaesthetic Fee?* Credit Card Direct Deposit (eg. via an internet funds transfer) Workers Compensation / Defence Force account / DVA Gold Card / Third Party Insurance Other Please advise details of payment 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 be contacted by your Anaesthetist prior to your procedure?* Yes Only if my Anaesthetist has specific issues they wish to discuss No (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 (Optional) Please advise your Email AddressPlease enter your email address below if you would like us to email you your form confirmation and reference number 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. Please read and confirm* I am aware there will be a fee from my Anaesthetist. I have been advised of, or will seek, Informed Financial Consent so that I am aware of the fees to be paid. I understand that if my account should fall into arrears, I accept that I will be charged collection and/or legal costs incurred.Is there anything else you would like to mention?* Yes No If yes, please provide the details hereHidden(Hidden) Days until operationHiddenIgnore (Hidden) NameThis field is for validation purposes and should be left unchanged.