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Paediatric Pre-op Health Questionnaire
"
*
" indicates required fields
NHI number
Patient Full Name
*
Date
*
DD slash MM slash YYYY
Patient Weight
*
Parent/Guardian Full Name
*
Contact Email Address
*
Contact Phone Mobile
*
Contact Phone Home
Patient Address
*
Street Address
Address Line 2
City
ZIP / Postal Code
It is important that you answer ALL the questions as accurately as possible. All information is sought to minimise any risk to your child and will be retained as part of your child’s confidential clinical records.
Does your child have any:
Allergies to food, medicine, latex, plasters etc
*
Yes
No
Please specify
*
Any dietary requirements
Yes
No
Please specify
*
Asthma
*
Yes
No
When was your last asthma attack?
*
Recent cough, cold or chest infection
*
Yes
No
Please specify
*
Breathing problems
*
Yes
No
Please specify
*
Kidney or urine problems
*
Yes
No
Please specify
*
Diabetes
*
Yes
No
Please specify
*
Has your child had:
Recent exposure in the last three weeks to childhood illnesses such as chickenpox / mumps / measles / rubella / whooping cough
*
Yes
No
Please specify
*
Their childhood immunisations
*
Yes
No
Previous operations
*
Yes
No
Please specify
*
Been in hospital for other reasons? e.g. Asthma
*
Yes
No
Please specify
*
Problems with an anaesthetic
*
Yes
No
Please specify
*
Family members who have had problems with an anaesthetic
*
Yes
No
Please specify
*
Rheumatic fever or heart problems
*
Yes
No
Please specify
*
Seizures or fits
*
Yes
No
Please specify
*
Bleeding problems
*
Yes
No
Please specify
*
Skin problems
*
Yes
No
Please specify
*
General & On Discharge
Was your child born prematurely
*
Yes
No
How many weeks?
*
Was she/he admitted to the Special Care Unit
*
Yes
No
How long were they admitted for?
*
Does your child have any other medical, developmental, behavioural conditions?
*
Yes
No
Please specify
*
Is your child taking any medication?
*
Yes
No
Medications
*
Add
Remove
Does your extended family have any other medical conditions or allergies (e.g. bleeding disorders etc)?
*
Yes
No
Please specify
*
Do you have any specific questions for the anaesthetist?
*
Yes
No
Please specify
*
Do you have your own transport?
*
Yes
No
Do you have access to Emergency Health Services?
Yes
No
Declaration
*
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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