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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
     
    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.