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Adult Pre-op Health Questionnaire
"
*
" indicates required fields
NHI number (if known)
Full Name
*
Your Email
*
Date of Birth
*
DD slash MM slash YYYY
Weight (in kg)
*
Height (in cm)
*
Address
*
Street Address
Address Line 2
City
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
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United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Please complete the questionnaire below selecting Yes, No, or ticking the appropriate box.
Have you ever had or do you currently have any of the following
Cardiac
High Blood Pressure?
*
Yes
No
Low Blood Pressure?
*
Yes
No
Do you take Blood Pressure medications?
*
Angina/Chest Pain/Palpitations?
*
Yes
No
Please specify
*
Heart Attack?
*
Yes
No
Coronary Surgery or procedures?
*
Yes
No
Stent
*
Yes
No
Artificial Heart Valve
*
Yes
No
How long ago since your previous Heart Attack,Coronary Surgery, Stent, or Artificial Heart Valve?
*
Heart Murmur
*
Yes
No
Implantable Cardiac Defibrillator (ICD)
*
Yes
No
How long ago since this device inserted?
*
Defibrillator
*
Yes
No
Pacemaker
*
Yes
No
How long ago was it inserted?
*
Blood Thinning Medication e.g. Warfarin/Pradaxa
*
Yes
No
Please specify
*
Blood disorder: Bruise easily
*
Yes
No
Blood disorder: Anaemia
*
Yes
No
Blood disorder: Blood clots in legs or lungs
*
Yes
No
How long ago?
*
Respiratory
Shortness of breath
*
Yes
No
On exertion or rest
*
Exertion
Rest
Persistent cough
*
Yes
No
On exertion or rest?
*
Exertion
Rest
Asthma
*
Yes
No
When was your last asthma attack?
*
Emphysema/Chronic Pulmonary Disease(COPD)/Obstructive Sleep Apnoea (OSA)
*
Yes
No
Please specify
*
Diabetes
*
Yes
No
How do you manage?
*
Insulin
Tablets
Diet Controlled
Hiatus hernia
*
Yes
No
Heart burn
*
Yes
No
Stomach ulcer
*
Yes
No
Kidney Disease
*
Yes
No
Renal Failure
*
Yes
No
Dialysis
*
Yes
No
Bladder problems
*
Yes
No
Bowel problems
*
Yes
No
Neurological
Epilepsy
*
Yes
No
Seizures
*
Yes
No
When was your last seizure?
*
Severe headaches
*
Yes
No
Stroke
*
Yes
No
Trans Ischemic Attack (TIA)
*
Yes
No
When was last stroke/TIA?
*
Blackouts
*
Yes
No
Alzheimers
*
Yes
No
Dementia
*
Yes
No
Mental health condition
*
Yes
No
Neurological condition
*
Yes
No
Please Specify
*
History of dura mater implants prior to 1992
*
Yes
No
History of Neurosurgery prior to 1992
*
Yes
No
Are you or have you in the past taken human derived growth hormone?
*
Yes
No
Which country was the derived growth hormone sourced from?
*
Other
Hepatitis
*
Yes
No
What type of Hepatits?
*
Type A
Type B
Type C
Unsure
Tuberculosis
*
Yes
No
How long ago?
*
HIV / AIDS
*
Yes
No
Psoriasis/Dermatitis
*
Yes
No
Please Specify
*
Skin ulcers/Current Wounds/Dressings
*
Yes
No
Please Specify
*
Current Skin Infections
*
Yes
No
Please Specify
*
Hospital Acquired Infections e.g MRSA/ESBL/VRE
*
Yes
No
Claustrophobia
*
Yes
No
Do you smoke?
*
Yes
No
Do you consume alcohol?
*
Yes
No
How many glasses/week?
*
Do you take social/recreational drugs?
*
Yes
No
Please specify and how often?
*
Mobility
Do you require mobility assistance?
*
Yes
No
Please specify
*
Do you have any difficulty getting yourself off a bed?
*
Yes
No
Please specify
*
Do you have any difficulty lying flat?
*
Yes
No
Please specify
*
Do you use a walker / stick / wheelchair?
*
Yes
No
Please specify
*
Are you prone to falls?
*
Yes
No
How long ago was your last fall?
*
Are you prone to fainting?
*
Yes
No
Do you have any implants or prostheses?
*
Yes
No
What implants or prostheses do you use?
*
Cochler
Joint
Plates
Screws
Hearing Aid
Other
Please specify
*
Women - Are you or could you be pregnant?
*
Yes
No
N/A
Allergies, Reactions or Sensitivities
Do you have any Allergies, Reactions or Sensitivities?
*
Yes
No
Do you have a list you can upload with your allergies with name and reaction?
*
Yes
No
Upload a list of your allergies
*
Max. file size: 256 MB.
Include a name and reaction. Allergic examples - Drugs/Medicine, Latex, Iodine, Plaster, Food, etc
Are you allergic to Drugs and/or Medicine?
*
Yes
No
Name and reaction you have to Drugs and/or Medicine
*
Are you allergic to Latex?
*
Yes
No
Reaction you have to latex
*
Are you allergic to Iodine?
*
Yes
No
Reaction you have to iodine
*
Are you allergic to Plaster?
*
Yes
No
Reaction you have to plaster
*
Are you allergic to Food?
*
Yes
No
Name and reaction you have to Food
*
Current medications
Medicines, tablets, inhalers, injections, eye drops etc.
Are you currently on any medication?
*
Yes
No
Do you have a list you can upload with your medications?
*
Yes
No
Attach medication/supplement
*
Add
Remove
Add attachments
Accepted file types: jpg, pdf, tiff, Max. file size: 256 MB.
Hospital Admissions / Operations / Procedures
Have you had any hospital admissions, operations procedures during the past 5 years?
*
Yes
No
Do you have a list you can upload with your hospital admissions, operations procedures?
*
Yes
No
Upload a list of your hospital admissions, operations procedures
*
Max. file size: 256 MB.
Include name, month/year, reason for admission
List
*
Name of hospital
Month/Year
Reason for Admission
Add
Remove
Patients under going General Anaesthetic or IV Sedation
Note: You will require adult supervision for 24 hours after your general anaesthetic
Will you be undergoing General Anaesthetic or IV Sedation during your surgery with Auckland Eye?
*
Yes
No
Have you had General Anaesthetic or IV Sedation in the past?
*
Yes
No
What type of anaesthetic have you had in the past?
*
General
Local
Have you or any family member had any problems with previous anaesthetics?
*
Yes
No
Family member had problems with previous anaesthetics, please explain
*
Do you suffer from motion sickness?
*
Yes
No
What level of motion sickness
*
Mild
Moderate
Severe
Do you have problems opening your mouth?
*
Yes
No
Previous jaw problems/injuries?
*
Yes
No
Please specify
*
Do you have dentures / partial plates / capped or loose teeth?
*
Yes
No
Specify
*
Dentures
Partial plates
Capped or loose teeth
Is your physical activity restricted by shortness of breath / chest pain / joint pain?
*
Yes
No
Specify
*
Shortness of breath
Chest pain
Joint pain
Do any of your blood relatives have any major illnesses?
*
Yes
No
E.g. Diabetes, Muscular Dystrophy, Malignant Hyperthermia, etc
Please specify
*
Do you have any specific questions you wish the Anaesthetist to answer prior to your surgery?
*
Yes
No
Please outline your questions for the Anaesthetist
*
Final Questions
Do you have any religious beliefs/practice or cultural needs that we should be aware of?
*
Yes
No
Please specify
*
Do you have any dietary requirements?
*
Yes
No
Please specify
*
Any other relevant or helpful health information you may wish to advise us of?
*
Yes
No
Please specify
*
How are you feeling about your upcoming procedure?
*
Declaration
Questionnaire completed by...
*
Patient
Family Member
Reception
Bookings Clerk
GP
Nurse
Consent
*
To the best of my knowledge the above information is correct and I authorise the use of this information for purposes directly related to my healthcare
Note: please contact our Pre Assessment Nurse via email
preassessment@aucklandeye.co.nz
for any additional assistance or clarification regarding this questionnaire
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