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Health Questionnaire

For Expedited Admissions
In order to expedite your admission process, I have provided an electronic ‘Health Questionnaire Form‘.

I would appreciate it if you could complete this form online. The information will allow me to start planning your anaesthetic in advance.

    1. Patient Information

    First Name

    Last Name

    Email Address

    Phone Number

    Your height in cm:

    Your weight in kg:

    Date of Birth (DD MMM YYYY):

    2. Procedure Details

    Which hospital are you booked into:

    Who is your surgeon:

    What date have you been booked in for your procedure (DD MMM YYYY):

    What procedure are you having:

    3. Anaesthetic History

    Has it ever been very difficult to get drips or needles into your veins:

       

    YesNo

     

    Has it ever been difficult to insert a breathing tube:

       

    YesNo

     

    Have you had problems with nausea or vomiting after anaesthetics:

       

    YesNo

     

    Are you allergic to Latex:

       

    YesNo

     

    Are you allergic to any medicines:

       

    YesNo

    Please list any medicines you are allergic to and what the reaction is:

    4. Health Information

    Have you ever had a heart attack or angina chest pains:

       

    YesNo

     

    Have you had heart bypass surgery or stents:

       

    YesNo

     

    Have you had a pacemaker inserted:

       

    YesNo

     

    Do you have any narrowing of your heart valves:

       

    YesNo

     

    Do you have an irregular heart beat:

       

    YesNo

     

    Are you on medication for high blood pressure:

       

    YesNo

     

    Do you have heart failure:

       

    YesNo

     

    Would you get short of breath going up steps:

       

    YesNo

     

    Do you snore or have Obstructive Sleep Apnoea:

       

    YesNo

     

    Do you use asthma puffers regularly:

       

    YesNo

     

    Do you use insulin injections for diabetes:

       

    YesNo

     

    Do you take tablets for Diabetes:

       

    YesNo

     

    Are you on Ozempic injections or tablets:

       

    YesNo

    IMPORTANT: If you are on Ozempic please do NOT take this medication for at least 14 days before your procedure. On the day before your operation you should only drink fluids and not have any solid food. These steps are necessary to protect you from the risk of vomiting under the anaesthetic.

     

    Have you ever had brain surgery:

       

    YesNo

     

    Have you ever had surgery on your neck spine:

       

    YesNo

     

    Have you ever had surgery on your lower back spine:

       

    YesNo

     

    Have you ever had a Deep Venous Thrombosis or a blood clot:          

       

    YesNo

     

    Do you have a bleeding condition like haemophilia:

       

    YesNo

     

    Do you take blood thinning medicines apart from Aspirin:

       

    YesNo

     

    Are you on dialysis for kidney disease:

       

    YesNo

     

    Have you ever had an organ transplant:

       

    YesNo

     

    Do you have problems with heartburn or reflux:

       

    YesNo

     

    Do you have a full upper denture:

       

    YesNo

    Is there anything else I should know about your health?

    Privacy – We collect the information set out above in order to provide you with medical services. We will keep your information secure and confidential. If necessary, we may pass your information on to other health practitioners for a second opinion or referral purposes.

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