Patient Questionnaire

Patient Pre-Op Questionnaire

PATIENT DETAILS

First Name

Last Name

Date of Birth

Gender

MaleFemaleOtherPrefer not to say

Contact phone numberPlease list the best number to contact on for all care-related questions.

Email

Are you responsible for the account?

YesNo

Name of the person responsible for the patient account

Contact Phone

Email

PROCEDURE DETAILS

Surgeon's Name

Hospital Name

Date of the procedure

Procedure Details

PATIENT HEALTH BACKGROUND

How has your health been over the last 3 weeks?

Height (cm) *

Weight (kg) *

Do you have any allergies? *

Please detail what you are allergic to and what is the reaction

Have you ever had anaesthetic before? *

YesNo

Details of Previous Anaesthetic

Have you ever had any issues with anaesthetic on any of the previous occasions? *

YesNo

Details of issues, including anaesthetic given, procedure and approximate date

Have any of your blood relatives had problems with anaesthetic in the past? *

YesNo/Don't know

Details of the anaesthetic issues

Do you take any regular medications? *

YesNo

Regular Medication Details

Do you regularly smoke or drink alcohol? *

YesNo

Alcohol and smoking details

PATIENT MEDICAL HISTORY

Do you have any heart or cardiovascular health issues? *

YesNo

Cardiovascular health issues include: high blood pressure, chest pains, angina, heart attacks, coronary artery stents, coronary artery bypass surgery, heart rhythm problems, having a pacemaker or defibrillator

Details of cardiovascular health issues

Do you experience shortness of breath climbing less than 2 flights of stairs or while walking for 30 minutes on flat ground? *

YesNo

Do you have obstructive sleep apnoea (OSA)? *

YesNo

Were you recommended to use a CPAP machine? *

YesNo

Details of sleep apnoea

Do you have asthma? *

YesNo

What is your regular treatment for asthma?

PufferOral steroid tabletsNone

Have you ever been admitted to Intensive Care because of your asthma? *

YesNo

Asthma details

Any other respiratory issues? *

YesNo

Details of other respiratory issues

Do you have diabetes? *

YesNo

How is your diabetes managed?

InsulinTabletsDietOther

Do you have gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers or hiatus hernia? *

YesNo

Please provide more details about the condition and how it is managed

Do you have a thyroid disease? *

YesNo

Do you have an enlarged thyroid gland (goitre?) *

YesNo

Current state of thyroid condition

Thyroid hormone levels are normal - confirmed by the blood test done within 12 monthsThyroid hormone levels appear to be normal - last blood test done over 12 months agoWhen lying flat, breathing becomes difficultUnsure

Please provide further details

Please upload any relevant medical documents

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Any documents relating to your care, such as specialist and GP letters, pathology results etc

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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