Preoperative Assessment Questionnaire

"*" 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' below or visit (drtofighi.com.au) from your desktop or laptop

You 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 Dr Tofighi is properly prepared for your anaesthetic, please complete this preoperative assessment 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 Dr Tofighi

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 Tofighi later via the contact form on his profile page (drtofighi.com.au)
* To provide additional information or ask questions to Dr Tofighi, 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 Dr Tofighi and for added security Anaesthetic Group does not store your completed questionnaire.

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Form (hidden)

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?

Date of Birth*

(select your date of birth using the calendar icon or enter it as dd/mm/yyyy eg. 01/05/1981)

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)

Phone Number(s)*

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)

This field is hidden when viewing the form

Age 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

Preoperative Assessment Questionnaire – Dr Farhood Tofighi

Patient Details:

Operation Details:

Patient Information:

Patient Details:

Health Information:

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

Other Health Information:

File Upload:

Other Details:

PATIENTS

SURGEONS

ANAESTHETISTS