Preoperative Assessment Form – Dr Amutha Samuel "*" 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 dramuthasamuel.com.au from your desktop or laptopYou will often be asked to complete a similar preoperative assessment questionnaire by the hospital before admission for their own records – this is not provided to your Anaesthetist. To ensure Dr Amutha Samuel 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 / JPG or photo of any results, medication lists 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 Dr Samuel later via the contact form on her profile page (dramuthasamuel.com.au) * To provide additional information or ask questions to Dr Samuel, 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.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? 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)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).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 HiddenAge in Months (hidden - auto calculated for <2y)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 Information:Height (cm)*(eg. 105cm is entered as 105)Estimate / Old Measurement H Height is an estimate or an old measurement Weight (kg)*(eg. 32kg is entered as 32)Estimate / Old Measurement W Weight is an estimate or an old measurement HiddenBMI Calculation (hidden - auto calculated)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) Birth information*(please select all that apply - it is very important we know if there were significant medical issues in the first twelve months of life including prematurity, time in the Special Care Nursery (SCN) or Neonatal Intensive Care Unit (NICU), or admissions to hospital for any reason) I had a normal birth without any issues I was born preterm / before 37 weeks I was born by caesarean section I spent time in SCN or NICU I was admitted to hospital before my 1st birthday There were perinatal issues (eg. during pregnancy or shortly after birth) Other / Unknown If the caesarean section was due to a congenital anomaly, failure to progress in labour, foetal distress, or another emergency reason, please mention it belowPlease provide detailsHave you ever been admitted overnight to hospital or had an anaesthetic?* Yes No HiddenHave you ever had any anaesthetic complications or problems?(REMOVED) 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 approximate date, name of hospital and details of each previous procedure / hospital visit*(if you have ever had any anaesthetic problems or anaesthetic complications (eg. severe nausea/vomiting, perioperative cardiac events etc), you must mention them here. Also, if you have ever needed a pre-med, or had another Anaesthetist suggest a pre-med might be helpful in the future, please mention this here. 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) 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 / Not that I am aware of What are you allergic to and what is the reaction?*Do you use regular medications, puffers or any injections?*(this includes all syrups, tablets, puffers/inhalers, patches, sprays, eye drops, any type of injections etc.) 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 with active ingredient if known + amount taken + how often you take it eg. 20mg, once each morning)Have you been unwell in the 4 weeks before your operation?*(symptoms that could impact on the safety of an anaesthetic include fevers, rigors (shivering sweats at night), a cold or flu, chesty or wet cough, respiratory symptoms, shortness of breath, runny nose, being obviously unwell, diarrhoea, vomiting, being off their food, being home from school/daycare, not playing as they normally would, bronchiolitis, pneumonia or any other illness recently) Yes - I have been unwell No - I have been well and playing normally N/A - My operation is in more than four weeks Please provide details*Patient Details:Height (cm)*(eg. 165cm is entered as 165)Weight (kg)*(eg. 70kg is entered as 70)HiddenBMI Calculation (hidden - auto calculated)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 If you have ever had any reactions to or issues with receiving anaesthesia in the past, it is very important you detail this below Have you ever had any anaesthetic complications or problems?* Yes No Unsure Please advise the approximate date, name of hospital and details of each previous procedure / hospital visit*(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 What are you allergic to and what is the reaction?*Do you take regular medications, puffers 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, GLP-1 receptor agonists (eg. Saxenda, Ozempic) or any anticoagulants (eg. Aspirin, Xarelto, Eliquis, Warfarin, Clexane)) Yes No If yes, please detail each medication + amount taken + how often you take it*(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)* If you would like to upload your medications list (such as a photo of the list from your GP, Webster-pak or even a photo of boxes with the prescription instructions), type UPLOAD in the text box below and the option to upload files will appear. You can then add additional medications in the text box belowTIP: Click "Save" below to send your special link to your mobile phone so you can take photos of the medication list/boxes and upload them to your form. Click "Save" again from your mobile, and you will be able to use the same special link, to finish your form here.Upload Medications (Adult)*You 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 Amutha Samuel 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: 5. 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 Health Information:Do you have any trouble with your heart or cardiovascular system, or have you ever been to a Cardiologist?*(this could include murmurs, holes in the heart, past visits to a cardiologist, past heart surgery) 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)Do you have shortness of breath when running slowly or playing with friends?* Yes No Other Do you have any trouble with your lungs or respiratory system, or have you ever seen a Respiratory/Sleep Specialist?*(please select all that apply – this could include asthma, obstructive sleep apnoea (OSA), snoring, cystic fibrosis, bronchiolitis or pneumonia within the last 3 months or any other lung / breathing / respiratory conditions) Yes - Asthma Yes - Obstructive Sleep Apnoea (OSA) Yes - Other No If yes, please select the following that 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 Important: If you have one, 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 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)Do you have diabetes?* Yes No Unsure / Other Diabetes type Type 1 Type 2 How old when diagnosed? How is your diabetes treated?(select all that apply) Insulin Tablets / Liquids 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 Samuel needs to maintain your BGL above this value whilst you undergo your procedure) Please provide details Have you been investigated for or diagnosed with a syndrome?* Yes No / Not that I am aware of Please provide more detailsDo 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 details Any trouble with your lungs or respiratory system, or have you ever seen a Respiratory/Sleep Specialist?*(please select all that apply – this could include asthma, obstructive sleep apnoea (OSA) with or without CPAP mask use, cystic fibrosis, pneumonia within the last 3 months, smoking-related problems or any other lung / breathing / respiratory conditions) Yes - Asthma Yes - Obstructive Sleep Apnoea (OSA) Yes - Other lung problems No If yes, please select the following that 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 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)Diabetes?* Yes No Other Diabetes type Type 1 Type 2 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 Samuel 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 that 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 that 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(please make sure you include your Neurologist 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)Rheumatoid arthritis, connective tissue disease or any other musculoskeletal issues?* Yes No If yes, please provide details(please make sure you include your Rheumatologist 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)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 or excessive bleeding?*(this could include deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia 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 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? Other Health Information: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 HiddenDAYS between Covid+ and Operation (hidden)HiddenWEEKS between Covid+ and Operation (hidden)HiddenDAYS between Covid+ and Today (no Op date) (hidden)HiddenWEEKS between Covid+ and Today (no Op date) (hidden)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:* HiddenDo you still have any symptoms? (REMOVED Sept24) HiddenSince COVID-19, have you been able to resume your usual exercise routine? (REMOVED Sept24)(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 sport or exercise routine, please write in the box below "No" and provide more details)Which of the following describes your mouth and teeth?*(please select all that apply) I am unable to open my mouth fully I have my own teeth only (with or without fillings) Loose tooth or teeth Chipped tooth or teeth Braces Wire retainer Caps No teeth yet Other Which of the following describes your mouth, teeth, and dentition?*(please select all that apply) I am unable to open my mouth fully I have my 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, Dymadon Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop Anti-inflammatories, eg. Nurofen, Voltaren, Celebrex, Mobic Tramadol, eg. Tramal Tapentadol, eg. Palexia 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, Dymadon Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop Anti-inflammatories, eg. Nurofen, Voltaren, Celebrex, Mobic Tramadol, eg. Tramal Tapentadol, eg. Palexia 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 things like neurological conditions (such as cerebral palsy or epilepsy), muscle, stomach, kidney, vascular or thyroid problems, cancer, blood disorders, psychiatric / cognitive / behavioural conditions (such as autism, anxiety or developmental disorders), or anything else that could affect your health or the care you receive from Dr Samuel) Yes No 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 Samuel) Yes No If yes, please include as much detail as possibleFile Upload:Would you like to upload any medical documents?(if you would like to upload any medical records, summaries, test results, specialist letters, or other supporting information, you can do so here. Alternatively, you can send these to Dr Amutha Samuel later via a message on her profile page - dramuthasamuel.com.auNoYesTIP: Click "Save" below to send your special link to your mobile phone so you can take photos of your medical documents and upload them to your form. Click "Save" again from your mobile, and you will be able to use the same special link, to finish your form here.Upload 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 Samuel 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: 12. Other Details:Do you have someone who can pick you up from hospital and care for you for the first 24 hours following discharge?* Yes No Name and mobile number of your carer(the person who will remain with you for the full 24 hours following the procedure. If there are multiple carers, please include their names, mobile numbers, and relationship to the patient) 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 Samuel may need to contact your other doctors to obtain test results, specialist letters, or other information. This allows a better understanding of your health, and is necessary to tailor an anaesthetic to your specific needs) 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)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 Please provide the name of your health fund and 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 / Third Party Insurance Defence Force account / DVA Gold Card Other Please advise details of payment here* Dr Amutha Samuel will be sent the information submitted via this questionnaire. Depending on your answers, Dr Samuel may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, Dr Samuel 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 Samuel prior to your procedure?* Yes Only if Dr Samuel has specific issues she 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 is required here, if it is different) (Optional) Please advise your Email Address(if you would like your form confirmation and reference number emailed to you, please enter your email address below) 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. 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. Your answers will be completely anonymous and will greatly help Dr Samuel 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 hereHiddenDays until operation (hidden - auto calculated)HiddenIgnore (hidden) PhoneThis field is for validation purposes and should be left unchanged.
