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Pre-op Health Questionnaire – Adult

"*" indicates required fields

Δ

NHI Number

Name*

First Last

Date of Birth*

Day

Month

Year

Email Address*

Phone Number*

Address*

Street Address Address Line 2 City ZIP / Postal Code Country

Height (in cm)*

Weight (in kg)*

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

Cardiometabolic Health

Do you have or have you experienced problems with your heart?*

Yes

No

Please specify*

Have you ever had heart surgery?*

Yes

No

Please specify*

Blood Thinning Medication e.g. Warfarin*

Yes

No

Please specify*

Diabetes*

Yes

No

Type*

Type 1

Type 2

How do you manage?*

Mobility

Do you require mobility assistance?*

Yes

No

Please specify*

Do you have any difficulty lying flat or getting yourself on/off a bed?*

Yes

No

Please specify*

Do you use a walker / stick / wheelchair?*

Yes

No

Are you able to transfer independently (standing transfer, walk a short distance, wheelchair to bed, vice-versa)*

Yes

No

Please specify*

Are you prone to falls?*

Yes

No

How long ago was your last fall?*

Respiratory Health

Do you have any problems with breathing?*

Yes

No

Persistent cough*

Yes

No

Please specify*

Neurologic Health

Have you experienced any of the following: Seizures, epilepsy, severe headaches, blackouts, fainting, vertigo*

Yes

No

If yes, when the last episode?*

Stroke/ Transient Ischemic Attack (TIA)*

Yes

No

When was last stroke/TIA?*

Alzheimer’s/Dementia*

Yes

No

Mental health condition*

Yes

No

Please specify*

Do you suffer from claustrophobia?*

Yes

No

Other

Do you have any communicable diseases such as: Hepatitis A/B/C, Tuberculosis (TB) or HIV/AIDS*

Yes

No

Please specify*

Current: Cuts, Bruises, Wounds, Skin infections*

Yes

No

Please specify*

Hospital acquired infections e.g. MRSA/ESBL/VRE*

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?*

Women – Pregnant or possibly pregnant?*

Yes

No

N/A

Allergies, Reactions or Sensitivities

Do you experience any Allergies, Reactions or Sensitivities?*

Yes

No

Are you allergic/sensitive to any Food and/or Medicine and/or other Materials like Latex, Iodine, Plaster/Tape?*

Yes

No

How would you like to provide us with your specific allergies and reactions?*

Type it into the form

Upload a list

Please specify your known allergies and reactions*

Please upload your list of known allergies and reactions*

Max. file size: 256 MB.

Current Medications

Medicines, tablets, inhalers, injections, eye drops, herbal remedies, homeopathic, complementary medicines, vitamins and other supplements, etc

Are you currently taking any medications?*

Yes

No

Are you on medications that may affect the surgery? e.g Doxazosin, Tamsulosin*

Yes

No

How would you like to provide us with your list of current medications?*

Type it into the form

Upload a list

Please list your current medications below*

Please upload your list of current medications*

Max. file size: 256 MB.

Hospital Admissions/Operations

Have you had any hospital admissions, operations or procedures during the past 5 years?*

Yes

No

How would you like to provide us with information regarding your hospital admissions, operations or procedures?*

Type it into the form

Upload a list

Hospital Admissions/Procedures Upload

Max. file size: 256 MB.

Hospital Admission History

Name of hospital

Month/Year

Reason for Admission

Cultural/Religious/Personal Considerations

Do you have any personal, cultural or religious preferences, needs or requirements that we can be aware of for your surgery?*

Yes

No

Please specify*

Confirm and Submit

Confirm*

To the best of my knowledge the above information is correct

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