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Patient Questionnaire

PRE-OPERATIVE ASSESSMENT QUESTIONNAIRE

DR OLAF SANDER

PATIENT DETAILS

Surname
Given Name:
Address:
Date of Birth:
Phone:
E-mail:
Type of Operation:
Surgeon:
Medicare No:
Date of Operation:
Hospital:
Private Health Fund:

ADMISSION DETAILS

What is your expected length of stay:
Number of Days:
Weight:
Height:
Enter your weight:
Enter your height:
Age:

ALLERGIES

Do you have allergies to medication, food, dressings, latex or rubber (balloons, gloves)?
Details:

MEDICATIONS

Do you take any anti-coagulant or blood thinning therapy? (Warfarin, Plavix, Aspirin, Xarelto, Pradaxa, Effient)
Date last taken #1:
 / 
 / 
Stop from date #1:
 / 
 / 
Do you take or have you taken any Steroids, NSAIDs?
Date last taken #2:
 / 
 / 
Stop from date #2:
 / 
 / 

REGULAR MEDICATIONS

Med #1:
Med #2:
Med #3:
Med #4:
Med #5:
Med #6:
Med #7:
Med #8:
Dose #1:
Dose #2:
Dose #3:
Dose #4:
Dose #5:
Dose #6:
Dose #7:
Dose #8:
Time #1:
Time #2:
Time #3:
Time #4:
Time #5:
Time #6:
Time #7:
Time #8:

PREVIOUS OPERATIONS / PROCEDURES

List all surgeries, including endoscopies, sedation procedures.
Operation #1:
Operation #2:
Operation #3:
Operation #4:
Operation #5:
Operation #6:
Operation #7:
Operation #8:
Year #1:
Year #2:
Year #3:
Year #4:
Year #5:
Year #6:
Year #7:
Year #8:
Hospital #1:
Hospital #2:
Hospital #3:
Hospital #4:
Hospital #5:
Hospital #6:
Hospital #7:
Hospital #8:

PREVIOUS ANAESTHETIC EXPERIENCE

Have you ever had a reaction to an Anaesthetic?
Has your direct family had a reaction to an Anaesthetic?
Have you ever had a reaction to a blood transfusion?
If Yes, details of Anaesthetic reaction?
If Yes, details of their reaction?
If Yes, details of your Blood Transfusion reaction?

GENERAL HEALTH CONDITIONS

1. High blood pressure:
1. Year Diagnosed / details:
2.
2. Year Diagnosed:
3. Coronary stents
3.
3. Date inserted:
4.
4. Year Diagnosed:
5. Pacemaker type:
6. Cancer:
5. Date of last check:
6. Type of cancer:
5. Date implanted:
6. Year diagnosed:
7.
7. Provide details:
8. Blood clots in your lung, legs or bleeding disorder:
9. Inherited blood disorder (e.g. Porphyria, Haemochromatosis):
8. Provide details:
9. Provide details:
10. Diabetes controlled by:
11.
12.
10. Year diagnosed:
11. Year diagnosed:
12. Provide details:
13. Sleep Apnoea:
13. Are you using a CPAP machine:
13. Year diagnosed:
14. Shortness of breath with:
14. Year diagnosed:
15. Pain / Discomfort lying flat:
16. Osteo-/Rheumatoid Arthritis:
17. Thyroid disease:
15. Provide details:
16. Affecting which joints / organs:
17. Provide details:
18.
18. Specify type (a,b,c):
18. Year diagnosed:
19. Kidney or bladder (or prostate) disease:
20. Do you have any oral fluid restrictions from your physician:
19. Provide details:
20. Provide details:
21. Hiatus hernia / Gastric reflux:
21.
21. Provide details:
22.
22. Provide details:
23. Motion sickness:
23.
23. Provide details:
24.
24. Treated or active:
24. Provide details:
25. Neuromuscular disease:
25. Year diagnosed:
25. Provide details:
26.
26. Provide details:
Female patients: Are you, or could you be pregnant?
Provide details:

GENERAL PRACTITIONER AND OTHER SPECIALISTS / HEALTH DIRECTIVE

Who is you regular GP and what is their best contact?
Please list any specialists, e.g. Cardiologist, Physician etc. that you have recently consulted.
Do you have an Advanced Health Directive? (A document of instruction about your health care)
Please provide details:

LIFESTYLE / AIDS / OTHER

Have you ever smoked:
How many years:
Daily amount:
Year ceased:
Do you drink alcohol:
Do you use recreational drugs:
How often:
Type:
Amount (STD):
Amount:
Do you require a special diet:
Details of diet:
1. Do you have:
2. Do you wear:
3. Do you use a:
1. Details:
2. Details:
3. Details:
Do you someone to look after you when discharged:
Any details:

OTHER HEALTH PROBLEMS

Please list any other health conditions you want your anaesthetist being aware of:

CONFIRM AND SUBMIT

The information I have supplied in this questionnaire is accurate and to the best of my knowledge.
Type your name:*
Date today:
Rating
4.5