Pre-op Health Questionnaire - Dr Rothwell * Anaesthetic Group

"*" indicates required fields

Step 1 of 5 – Please complete the Patient and Operation Details below:

Please note: This form can be completed from ANY device

If you would rather complete this on a bigger screen, please click ‘Save Your Form To Complete Later’ below or visit DrJRothwell.com.au from your desktop or laptop

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Form (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.

You will need approximately 15 minutes to fill in this form. 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 each page.

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
* You can click “Save Your Form to Complete Later” at any time, even if you haven’t finished a page completely
* 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.

Patient Details:

Patient's Name*

First Last

Are you the patient?*

Yes

Your Name

Relationship to Patient

Please complete all of the following questions based on the patient
ie. 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)*

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*

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 own

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Age (Hidden – auto calculated)

Operation Details:

Surgeon*

Hospital

Operation*

(the procedure being performed)

Date of Operation

Why are you having this operation?

(what symptoms or diagnosis made you decide to undergo this procedure?)

Pre-op Health Questionnaire – Dr Rothwell

Patient Details:

Operation Details:

Patient Details:

Do you have, or have you ever had, any of the following?

File Upload

Other Details:

PATIENTS

SURGEONS

ANAESTHETISTS