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Adult Pre-op Health Questionnaire

"*" indicates required fields

NHI number (if known)

Full Name*

Your Email*

Date of Birth*

Weight (in kg)*

Height (in cm)*

Address*

Street Address Address Line 2 City 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

Low Blood Pressure?*

Yes

Do you take Blood Pressure medications?*

Angina/Chest Pain/Palpitations?*

Yes

Please specify*

Heart Attack?*

Yes

Coronary Surgery or procedures?*

Yes

Stent*

Yes

Artificial Heart Valve*

Yes

How long ago since your previous Heart Attack,Coronary Surgery, Stent, or Artificial Heart Valve?*

Heart Murmur*

Yes

Implantable Cardiac Defibrillator (ICD)*

Yes

How long ago since this device inserted?*

Defibrillator*

Yes

Pacemaker*

Yes

How long ago was it inserted?*

Blood Thinning Medication e.g. Warfarin/Pradaxa*

Yes

Please specify*

Blood disorder: Bruise easily*

Yes

Blood disorder: Anaemia*

Yes

Blood disorder: Blood clots in legs or lungs*

Yes

How long ago?*

Respiratory

Shortness of breath*

Yes

On exertion or rest*

Exertion

Rest

Persistent cough*

Yes

On exertion or rest?*

Exertion

Rest

Asthma*

Yes

When was your last asthma attack?*

Emphysema/Chronic Pulmonary Disease(COPD)/Obstructive Sleep Apnoea (OSA)*

Yes

Please specify*

Diabetes*

Yes

How do you manage?*

Insulin

Tablets

Diet Controlled

Hiatus hernia*

Yes

Heart burn*

Yes

Stomach ulcer*

Yes

Kidney Disease*

Yes

Renal Failure*

Yes

Dialysis*

Yes

Bladder problems*

Yes

Bowel problems*

Yes

Neurological

Epilepsy*

Yes

Seizures*

Yes

When was your last seizure?*

Severe headaches*

Yes

Stroke*

Yes

Trans Ischemic Attack (TIA)*

Yes

When was last stroke/TIA?*

Fainting*

Yes

Alzheimers*

Yes

Dementia*

Yes

Mental health condition*

Yes

Neurological condition*

Yes

Please Specify*

History of dura mater implants prior to 1992*

Yes

History of Neurosurgery prior to 1992*

Yes

Are you or have you in the past taken human derived growth hormone?*

Yes

Which country was the derived growth hormone sourced from?*

Other

Hepatitis*

Yes

What type of Hepatits?*

Type A

Type B

Type C

Unsure

Tuberculosis*

Yes

How long ago?*

HIV / AIDS*

Yes

Psoriasis/Dermatitis*

Yes

Please Specify*

Skin ulcers/Current Wounds/Dressings*

Yes

Please Specify*

Current Skin Infections*

Yes

Please Specify*

Hospital Acquired Infections e.g MRSA/ESBL/VRE*

Yes

Claustrophobia*

Yes

Do you smoke?*

Yes

Do you consume alcohol?*

Yes

How many glasses/week?*

Do you take social/recreational drugs?*

Yes

Please specify and how often?*

Mobility

Do you require mobility assistance?*

Yes

Please specify*

Do you have any difficulty getting yourself off a bed?*

Yes

Please specify*

Do you have any difficulty lying flat?*

Yes

Please specify*

Do you use a walker / stick / wheelchair?*

Yes

Please specify*

Are you prone to falls?*

Yes

How long ago was your last fall?*

Are you prone to fainting?*

Yes

Do you have any implants or prostheses?*

Yes

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

N/A

Allergies, Reactions or Sensitivities

Do you have any Allergies, Reactions or Sensitivities?*

Yes

Do you have a list you can upload with your allergies with name and reaction?*

Yes

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

Name and reaction you have to Drugs and/or Medicine*

Are you allergic to Latex?*

Yes

Reaction you have to latex*

Are you allergic to Iodine?*

Yes

Reaction you have to iodine*

Are you allergic to Plaster?*

Yes

Reaction you have to plaster*

Are you allergic to Food?*

Yes

Name and reaction you have to Food*

Current medications

Medicines, tablets, inhalers, injections, eye drops etc.

Are you currently on any medication?*

Yes

Do you have a list you can upload with your medications?*

Yes

Attach medication/supplement*

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

Do you have a list you can upload with your hospital admissions, operations procedures?*

Yes

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

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

Have you had General Anaesthetic or IV Sedation in the past?*

Yes

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

Family member had problems with previous anaesthetics, please explain*

Do you suffer from motion sickness?*

Yes

What level of motion sickness*

Mild

Moderate

Severe

Do you have problems opening your mouth?*

Yes

Previous jaw problems/injuries?*

Yes

Please specify*

Do you have dentures / partial plates / capped or loose teeth?*

Yes

Specify*

Dentures

Partial plates

Capped or loose teeth

Is your physical activity restricted by shortness of breath / chest pain / joint pain?*

Yes

Specify*

Shortness of breath

Chest pain

Joint pain

Do any of your blood relatives have any major illnesses?*

Yes

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

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

Please specify*

Do you have any dietary requirements?*

Yes

Please specify*

Any other relevant or helpful health information you may wish to advise us of?*

Yes

Please specify*

How are you feeling about your upcoming procedure?*

Declaration

Questionnaire completed by...*

Note: please contact our Pre Assessment Nurse via email preassessment@aucklandeye.co.nz for any additional assistance or clarification regarding this questionnaire

Adult Pre-op Health Questionnaire

Have you ever had or do you currently have any of the following

Cardiac

Respiratory

Neurological

Other

Mobility

Allergies, Reactions or Sensitivities

Current medications

Hospital Admissions / Operations / Procedures

Patients under going General Anaesthetic or IV Sedation

Final Questions

Declaration

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