Patient Pre – Operative Questionnaire – Professional Anaesthesia Services

Personal Details

Title

Given Name

Surname

Age

Occupation

Contact Details

Suburb

Phone Number

Mobile Number

Medicare Details

Medicare Yes No

DVA Card Yes No

Do you have Private Health Insurance? Yes No

Your Anaesthetist is

General Practitioner

Doctors Name

Doctors Contact Number

Do you consent to me contacting them to discuss details of your medical history? Yes No

Surgery Details

Proposed date of surgery

Proposed Surgery

Hospital

Surgeon

Surgical and Anaesthetic History

Have you had any operations in the past?
Yes No

If yes, please give details

Have you had any problems or difficulties with previous anaesthetics?
Yes No

If yes, please give details

Have any of your blood relatives had problems with anaesthetics?
Yes No

If yes, please give details

Health Questionnaire

Do you have allergies or adverse reactions?
Yes No

If yes, please give details

What is your height?

What is your weight?

Airway Questions

Do you have any loose or chipped teeth?
Yes No

If yes, please give details

Do you have dentures, caps, crowns, bridges, dental implants?
Yes No

If yes, please give details

Do you have any jaw problems or any difficulty opening your mouth?
Yes No

If yes, please give details

Heart and Circulation Questions

Do you suffer from High Blood Pressure?
Yes No

If yes, please give details

Do you suffer from Chest Pain?
Yes No

If yes, please give details

Do you suffer from Angina?
Yes No

If yes, please give details

Have you had a heart attack?
Yes No

If yes, please give details

Do you suffer from palpitations?
Yes No

If yes, please give details

Have you suffered from heart failure??
Yes No

If yes, please give details

Do you have a pacemaker or have you had a valve replacement?
Yes No

If yes, please give details

Have you had a stroke or mini stroke?
Yes No

If yes, please give details

Do you suffer from ankle swelling?
Yes No

If yes, please give details

Have you ever had a blood transfusion?
Yes No

If yes, please give details

Have you previously had heart surgery?
Yes No

If yes, please give details

Do you suffer from any other heart condition?
Yes No

If yes, please give details

Respiratory Questions

Do you smoke or have you ever smoked?
Yes No

If yes, please give details

Do you suffer from Asthma?
Yes No

If yes, please give details

Have you been hospitalised for Asthma?
Yes No

If yes, please give details

Do you regularly use a puffer?
Yes No

If yes, please give details

Do you suffer from bronchitis or emphysema?
Yes No

If yes, please give details

Do you snore or have confirmed sleep apnoea?
Yes No

If yes, please give details

Do you suffer shortness of breath?
Yes No

If yes, please give details

Other Systems

Do you suffer from Kidney Problems?
Yes No

If yes, please give details

Do you suffer from Diabetes?
Yes No

If yes, please give details

Do you have problems passing urine?
Yes No

If yes, please give details

Do you suffer from stomach ulcer or hiatus hernia?
Yes No

If yes, please give details

Do you suffer from Liver disease, hepatitis, jaundice?
Yes No

If yes, please give details

Do you suffer from Epilepsy?
Yes No

If yes, please give details

Do you have a thyroid condition?
Yes No

If yes, please give details

Do you suffer from motion sickness?
Yes No

If yes, please give details

Do you have an infectious disease?
Yes No

If yes, please give details

Do you drink alcohol?
Yes No

If yes, please give details

I acknowledge these details will be saved to form part of my medical records.