Pre-op Health Questionnaire – Dr Rothwell "*" indicates required fields Step 1 of 5 – Please complete the Patient and Operation Details below: 0% URLThis field is for validation purposes and should be left unchanged.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 DrJRothwell.com.au from your desktop or laptopThis field is hidden when viewing the formForm (hidden)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 Rothwell 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 5 minutes of inactivity for security and privacy reasons), or if your internet connection is unstable. 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, weight (kg) & height (cm) – A scanned PDF or JPG of any results, medications or letters you wish to send your Anaesthetist Tips: * To go back to a previous page please only use the “PREVIOUS” button at the bottom of the page * You can send Dr Rothwell extra files later via the contact form on his profile page at DrJRothwell.com.au * 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). * Some of the fields are mandatory and are marked with an asterisk (*) * There is room at the very end of the questionnaire for you to add any additional information or ask questions to Dr Rothwell – click YES to “Is there anything else you would like to mention?” for the box to appear. 🔒 This is a secure form. Once you submit this form, it is immediately sent to Dr Rothwell and for added security Anaesthetic Group does not store your completed questionnaire. Patient Details:Patient's Name* First Last Preferred Name(optional – how would you like to be addressed)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* Female Male Other / Non-Binary 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“ If you would like to receive a confirmation of this form, you will need to enter a valid email address above. Date of Birth* 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 ownThis field is hidden when viewing the formAge (Hidden – auto calculated)Operation Details:Surgeon*HospitalOperation*(the procedure being performed)Date of Operation(select the operation date using the calendar icon or enter it as dd/mm/yyyy eg. 01/02/2026) DD slash MM slash YYYY Why are you having this operation?(what symptoms or diagnosis made you decide to undergo this procedure) Patient Details:Height (cm)*(eg. 165cm is entered as 165)Weight (kg)*(eg. 70kg is entered as 70)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 advise the details of each previous procedure including the hospital, surgeon and yearAdd a new line for each procedure by clicking on the (+) symbol. Alternatively you can include this information in the text box below. (If you have undergone a lap band (laparoscopic gastric banding) procedure it is very important you mention it here)ProcedureHospitalSurgeonYear Add RemovePlease mention any other anaesthetic details here(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?* 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?*MedicationsDo you take regular medications?*(this includes all syrups, tablets, puffers, patches, sprays, eye drops, any type of injections etc.) Yes No Do you take any blood thinners, anticoagulant or anti platelet medications?*(this could include, but is not limited to, heparin, warfarin, rivaroxaban, dabigatran, apixaban, enoxaparin, aspirin, clopidogrel, ticagrelor). It is very important that I know this information) Yes No Do you take any GLP-1 receptor agonists or weight loss medications?*(these medications, commonly prescribed for diabetes or weight loss, can deliberately delay gastric emptying and significantly affect how anaesthesia works in your body. Common brand names include Ozempic, Mounjaro, Wegovy, Saxenda, and Trulicity etc. It is VERY important for your safety that your Anaesthetist is aware if you take them. In the medication box below, please make sure you enter the medication name, dosage, and date of last dose) Yes No Please note: You can send Dr Rothwell your medications by typing a list, uploading a file / picture or entering text. You can use one method or even combine all three, whichever works best for you. Medications (List)Add a new line for each medication by clicking on the (+) symbol. Alternatively you can include this information in the text box below.Drug NameDose (mg/mcg)Time of day / Last dose Add RemoveMedications (Upload)You can upload files by clicking SELECT FILES to locate them, or by using DRAG AND DROP from your file browser into the box below. Tip: Click “Save your Form” to email yourself a link, then take a photo and upload your medication list, Webster-pak, or prescription boxes from your phone. Click “Save your Form” again and return to complete this on your computer. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 8 MB, Max. files: 5. Include any other medication information here(please list each medication on a new line eg. medication name with active ingredient if known + amount taken + how often you take it eg. 20mg, once each morning. IMPORTANT: If your surgeon has advised you to cease any medications or specified when to take the last dose, please mention it here)Please check with your surgeon if you are required to cease medications which increase bleeding eg. (not limited to) Clopidogrel, apixaban, warfarin.Do you regularly take any non-prescribed medications, recreational drugs, herbal medicines or any other substances?*(this includes all herbs, vitamins and supplements like St John’s Wort, Ginkgo, Echinace, CBD oil, and over-the-counter painkillers or anticoagulants) Yes No If yes, please detail each with the amount taken and how often you take it*Please cease all non-prescribed products for at least a week prior to your operation due to the effect they can have on bleeding and recoveryLifestyleDo 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 In planning my anaesthetic, I need to know accurately your alcohol intakeIf yes, please detail what you drink and approximately how many alcoholic drinks you had in the last weekWhat type of physical activity are you able to do? Light intensity – eg. walking Moderate intensity – eg. swimming, tennis, golf Vigorous intensity – eg. running, HIIT workouts 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. 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(please make sure you include your Cardiologist’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)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 detailsAny 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: Bring your CPAP mask and machine with you to hospital as it may assist your recovery from general anaesthesiaPlease provide more details(please make sure you include your Respiratory or Sleep Doctor’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)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 This field is hidden when viewing the form(Hidden) DAYS between Covid+ and OperationThis field is hidden when viewing the form(Hidden) WEEKS between Covid+ and OperationThis field is hidden when viewing the form(Hidden) DAYS between Covid+ and Today (no Op date)This field is hidden when viewing the form(Hidden) WEEKS between Covid+ and Today (no Op date)Have you fully recovered?(if you are still experiencing any symptoms, or have not been able to return to your usual sport or 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. Dr Rothwell needs to maintain your BGL above this value whilst you undergo your procedure)Please advise your medication and doses(If you have not already listed this medication in your medications list above, please make sure you include it here. It is very important that I know this information)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 or gastric sleeve surgery Other Please provide detailsThyroid disease?* Yes No Other Other(please 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 detailsNeurological Condition?*(this could include a stroke, mini-stroke, TIA, multiple sclerosis, Parkinson’s disease or epilepsy) Yes No If yes, please provide details(please make sure you include your Neurologist’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)Rheumatoid arthritis, connective tissue disease or any other musculoskeletal issues?* Yes No If yes, please provide details(please make sure you include your Rheumatologist’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)Kidney condition?* Yes No If yes, please provide details(please make sure you include your Nephrologist, Kidney or Dialysis doctor’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)Blood clots, excessive bleeding or any condition that may increase your risk of these?*(this could include deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia, thalassaemia, von Willebrand or another condition) Yes No If yes, please provide details(please make sure you include your Haematologist or Blood doctor’s name and contact information as well as the reason for the visit(s) and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)Cancer?* Yes No If yes, please provide details including when and what treatment you received or are receiving?(please include your Oncologist’s name and contact details if applicable, the reason for the visit(s), and whether there is ongoing follow-up. If you can provide an approximate date of your last visit, that would also be helpful)Is there a chance you could be pregnant? Yes No If you are pregnant, how many weeks are you / would you be today? Have you had blood tests done recently? Yes No Unsure Please select which pathology company/companies 4Cyte Pathology Australian Clinical Labs Douglass Hanly Moir Pathology Laverty Pathology NSW Health Pathology Unknown Other UntitledWith regards to your teeth or dentition – what do you have?*(please select all that apply) I am unable to open my mouth fully 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 provide more details(is there a reason why your mouth doesn’t open fully?)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 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 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 Dr Rothwell) 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 Dr Rothwell later via a message on his 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 Dr Rothwell in the box below. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 8 MB, Max. files: 6. Other Details:Are you planning to stay overnight in hospital?* Yes No / Unsure Please confirm that you have someone to collect you from hospital and who can help you for the first 24 hours?* Yes – I have someone to help me for 24 hours, and I will not drive, sign documents, or undertake activities requiring coordination For the 24 hours after your anaesthetic, we advise that you must not drive, sign important documents or undertake activities where coordination is required.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 Dr Rothwell 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 NumberDo 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 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*Dr Rothwell will be sent the information submitted via this questionnaire. Depending upon your answers, Dr Rothwell may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, Dr Rothwell may be satisfied with the information submitted and be ready to proceed with your anaesthetic as is.Would you like to be contacted by Dr Rothwell prior to your procedure?* Yes Only if Dr Rothwell has specific issues he 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)What are the Risks of Anaesthesia?*There is no safer place in the world to undergo anaesthesia than in Australia. However, like anything we do to you there are risks of side effects and complications you need to be informed of. Some people are at increased risk of complications because of health problems such as heart or lung disease, diabetes, obesity, age and/or the type of surgery they are undergoing. As your anaesthetist I am a highly trained medical specialist who will carefully assess your health prior to your anaesthetic, thus it is important to see me in a formal consultation prior to your surgery date. This allows me time to assess you and then discuss what I will be doing for your anaesthetic, as well as warn you of the material risks, and any risks specific to your circumstances. It also allows me to organise any other investigations that may be required prior to going ahead with your surgery. These could include things such as heart or lung tests. These may be required so that I can give you the highest level of care you would expect. Remember, as a specialist anaesthetist I do not just give you a nice sleep and have you wake up as comfortable as possible. My biggest role is to keep you safe and alive. Common side effects and complications include: Pain and/or bruising at the site of injections/drips Nausea or vomiting Headache Sore throat Dry or cut lips Blurred/double vision and dizziness Temporary breathing difficulties Problems passing urine Less common side effects and complications include: Muscle aches and pains Weakness Mild allergic reactions – itching or rash Temporary nerve damage Uncommon side effects and complications include: Damage to teeth and dental work Being awake under general anaesthesia (awareness) Damage to voice box/vocal cords which can cause a temporary hoarse voice Allergic reactions and/or asthma Blood clot in the leg Seizures Chest infection (more likely if you smoke) Permanent nerve damage due to pressure during surgery Worsening of a medical condition Rare risks which may cause significant impairment or death include: Severe allergy or shock Stroke or heart attack Vomit in the lungs (aspiration pneumonia) Nerve/Eye damage Paralysis Blood clot in the lungs Brain damage Death Please note that the more serious risks listed above are very rare, but I have a duty of care to inform you of these. We will discuss risks in person either during a consultation or on the day of surgery. You are very welcome to ask me any questions you have in relation to risks. I have read and accept the above risksBy 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 Rothwell may print this information out at the hospital on your day of surgery, and add it to your hospital record.Would you be willing to fill in a short Patient Experience Survey form after your procedure?(if you select Yes, you will be sent a short survey to be filled in after your procedure. Most questions are optional. Your answers will be completely anonymous and will greatly help Dr Rothwell in understanding your experience and improving care for patients) Yes No Is there anything else you would like to mention?* Yes No If yes, please provide the details hereThis field is hidden when viewing the form(Hidden) Days until operationThis field is hidden when viewing the formIgnore (Hidden)This field is hidden when viewing the formOSA (hidden)This field is hidden when viewing the formGLP-1
