Preoperative Assessment Form - Dr Daniel Friedgut

"*" 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 anaestheticgroup.com.au from your desktop or laptop

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 Friedgut is properly prepared for your anaesthetic, please complete this pre-op health questionnaire to the best of your ability.

This form will take approximately 15 minutes to complete. Clicking the “Save Your Form to Complete Later” button at the bottom of each page will enable you to save your answers at any time – for example, if you have an unstable internet connection, cannot finish it in one session (under 30 minutes), or wish to complete it on another device.

To enable you to complete your questionnaire as quickly as possible, please have on hand:
– 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 Dr Friedgut

Tips:
* To go back to a previous page please only use the “PREVIOUS” button at the bottom of the page
* You can send Dr Friedgut extra files later via the contact form on his profile page
* 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 Friedgut – 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*

Hidden

Age (Hidden – auto calculated)

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

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?)

Stop! We have calculated the patient’s age, based on the date of birth you entered above as “0” years old.
If the patient is not a baby, please scroll back up and update the date of birth to the correct date.

Or, please tick the box below to confirm the date of birth is correct*

I confirm this form is being filled in for a baby

Preoperative Assessment Form – Dr Daniel Friedgut

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