Pre-Op Questionnaire

Anaesthesia Assessment - Patient Questionnaire

Anaesthesia Specialist Pre Op Questionnaire

Please complete the questionnaire below. Please answer all questions as accurately as possible. All information is sought to minimise your risk.

Family name:

First name(s):

Address:

Contact phone no:

Date of Birth:

Male or Female

Male

Female

General Practitioner:

General Practitioners phone no:

NHI no:

Insurance company:

Email:

Inpatient/Daycare

Date:

Place:

Surgeon:

Anaesthetist:

Proposed surgery:

Health Questionnaire

1. Your weight (kgs):

2. Your Height (metres):

3. Do you suffer from, or have you ever suffered from, the following:

Chest pains /tightness or angina

Yes

Shortness of Breath

Yes

Previous Rheumatic Fever

Yes

Asthma

Yes

Previous heart attack

Yes

Emphysema or bronchitis

Yes

Palpitations

Yes

Tuberculosis

Yes

Heart murmur

Yes

Obstructive sleep apnoea

Yes

High blood pressure

Yes

Persistent cough

Yes

Artificial heart valve or pacemaker

Yes

Stroke or seizures

Yes

Hiatus hernia / heartburn / indigestion

Yes

Jaundice or hepatitis

Yes

Diabetes - oral medication

Yes

Thyroid disease

Yes

Diabetes - insulin dependent

Yes

Previous DVT or lung embolus

Yes

Kidney Disease

Yes

Bleeding or clotting disorder

Yes

Rheumatoid arthritis

Yes

Motion Sickness

Yes

4. Do you smoke?

Yes

If so how many per day?

5. Do you drink alcohol?

Yes

If "yes", how much?

How often?

6. Risk of exposure to hepatitis?

Yes

7. If you answered "yes" to any of the above, please give further details below:

8. Please list previous surgery, including year and hospital if known:

Surgery

Date

Hospital

Surgery

Date

Hospital

Surgery

Date

Hospital

Name of patient:

9. What medications (including herbal) and/or drugs are you taking?

Medication

Dose

Time taken

Medication

Dose

Time taken

Medication

Dose

Time taken

10. Do you have problems with opening your mouth? (eg. previous jaw problems)

Yes

11. Have you been told of any difficulties during your anaesthetic?

Yes

12. Do you have dentures, partial plate, capped or loose teeth?

Yes

13. What physical activities do you take part in on a regular basis? (tick those that apply)

Other: (specifiy)

14. How may flights of stairs can you climb without getting out of breath?

One Flight

Two Flights

Three flights or more

15. My activity is restricted by:

Shortness of breath

Chest pain

Joint pain

16. Do you allergies to medications, tablets, plasters, food LATEX or any other substance?

Yes

If "yes" please specify:

Substance

Type of reaction

Substance

Type of reaction

17. Are there major illnesses, to your knowledge, among your blood relatives?
e.g. diabetes, muscular dytrophy, malignant hyperthermia

Yes

If "yes" please specify:

Disease

18. Have you or any of your family had problems with an anaesthetic?

Yes

If "yes" please outline:

19. Do you suffer from any other condition, not covered elsewhere, that you feel we should know about?

Yes

If "yes" please outline:

20. Do you have any concerns or questions about your anaesthetic?

Yes

If "yes" please outline:

21. Do you wish to see your anaesthetist before coming to hospital?

Yes

22. WOMEN ONLY - Are you or could you be pregnant?

Yes

I give permission for my / my child's medical records and investigation results to be accessed for the purpose of assisting in my anaesthetic.

Yes

The above details have been completed by:

Patient

Guardian

Relative

Other (specify)

Date

Print name:

If you have urgent queries, please contact your anaesthetist at his/her rooms or your surgeon.

If your anaesthetist beleives there are significant risks identified in this questionnaire, he/she may contact you to make an appointment before surgery.

Please bring all your medications with you to the hospital.

Additional comments:

If you are human, leave this field blank.

WHERE WE ARE

Northern Clinic
212 Wairau Rd
Glenfield
Auckland 0627

CONTACT US

Email: office@anaesthesiaspecialists.co.nz
Phone: 09-441 3913
Hours: 8.30 – 16.30

POSTAL ADDRESS

PO Box 101-641
NSMC 0745

Practice Manager – Kim Pope

Pre-Op Questionnaire

Anaesthesia Assessment - Patient Questionnaire

Health Questionnaire

3. Do you suffer from, or have you ever suffered from, the following:

8. Please list previous surgery, including year and hospital if known:

9. What medications (including herbal) and/or drugs are you taking?

If "yes" please specify:

If "yes" please specify:

If you have urgent queries, please contact your anaesthetist at his/her rooms or your surgeon.

If your anaesthetist beleives there are significant risks identified in this questionnaire, he/she may contact you to make an appointment before surgery.

Please bring all your medications with you to the hospital.

WHERE WE ARE

CONTACT US

POSTAL ADDRESS

Contact Us

FIND US