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?

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Privacy Policy – 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.