Pre-op Anesthetic Assessment Form
Personal details
Name
*
First Name
Last Name
Date of Birth
*
Please select a day
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Day
Please select a month
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Please select a year
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Year
Sex
*
Email address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Height
*
Weight
*
Are you filling out this form for yourself?
*
Helper's details
Name
*
First Name
Last Name
Relationship to patient
*
e.g. parent, daughter/son, friend
Phone Number (if different)
Please enter a valid phone number.
Format: (000) 000-0000.
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Next
Doctors' details
Do you have a regular GP?
*
Who is your GP?
Name & Clinic
Do you see any specialists?
*
Who are your specialists?
Name & Specialty
Are you happy for me to contact your other doctors regarding your care?
*
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Next
Operation details
What operation are you having?
*
Who is your surgeon/proceduralist?
*
When is your operation?
*
Where is your operation?
*
Name of hospital
Why are you having this operation?
*
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Next
Past Surgical & Anaesthetic History
Have you had an operation before?
*
Please list all previous operations:
*
i.e. name of operation, hospital, year (if known)
Have you had an anaesthetic before?
*
What types of anaesthetic have you had before? (select all that apply)
*
General anaesthetic
Spinal/epidural anaesthetic
Local anaesthetic
Sedation
Not sure
Have you ever had problems with an anaesthetic?
*
Inadequate pain relief
Nausea or vomiting
Difficult veins
Difficult breathing tube
Drug reaction
Awareness
Other
*NONE OF THE ABOVE*
Please provide details:
*
Has any of your blood relatives had a reaction to an anaesthetic?
*
Please provide details:
*
Regarding your teeth, select all that apply:
*
I have a loose tooth
I have missing teeth
I have had dental work
I have dentures
*NONE OF THE ABOVE*
Please provide details:
*
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Medications & Allergies
Do you take any medications or supplements? (e.g. tablets, injections, puffers)
*
Please list all your current medications:
*
Including medication, dose and frequency (e.g. aspirin 100mg daily)
Have you been instructed to change or stop any medications prior to surgery?
*
Please describe those instructions:
*
Do you have any allergies? (food, drug, latex, etc.)
*
Please provide details:
*
Including substance and reaction (e.g. codeine - nausea)
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Substance use
Smoking history
*
Current smoker
Former smoker
*NEVER*
For how many years have you smoked?
*
< 1 year
1-10 years
10-20 years
20-40 years
> 40 years
How many cigarettes do you smoke on an average day?
*
< 5 per day
5-10 per day
10-20 per day
20-40 per day
> 40 per day
How long ago did you quit smoking?
*
< 1 month ago
1-6 months ago
> 6 months ago
For how many years did you smoke?
*
< 1 year
1-10 years
10-20 years
20-40 years
> 40 years
How many cigarettes did you smoke on an average day?
*
0-5 per day
5-10 per day
10-20 per day
20-40 per day
> 40 per day
Alcohol history
*
Most days
Occasionally
Rarely
*NEVER*
Please describe your typical daily intake of alcohol:
*
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Investigations
Have you had any blood tests in the past month?
*
Please provide details:
*
i.e. location, date, result (if known)
Have you had any medical imaging in the past month? (e.g. X ray, CT, MRI)
*
Please provide details:
*
i.e. location, date, result (if known)
Have you had any of the following tests in the past year?
*
Stress test
ECG (heart electrical trace)
Echocardiogram (heart ultrasound)
Lung function test
Sleep studies
*NONE OF THE ABOVE*
Please provide details:
*
i.e. location, date, result (if known)
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Recent health
What is your present level of physical activity? (select one or more)
*
Regular aerobic exercise (e.g. jogging, cycling, swimming)
Regular resistance exercise (e.g. lifting weights)
Regularly walk up stairs or hills
Normal childhood activity (e.g. playground)
Physical work as part of my job
Physical work around the house
Walking outside
Walking inside
Unable to walk
Other
Please provide details:
*
i.e. location, date, result (if known)
Have you had any of the following symptoms in the past week?
*
Chest pain
Dizziness / fainting / collapse
Breathlessness with ordinary activity
Breathlessness at rest
Breathlessness when lying flat
*NONE OF THE ABOVE*
Please provide details:
*
Have you had any respiratory illnesses in the past week?
*
Runny nose
Sore throat
Dry cough
Chesty cough
Fever
*NONE OF THE ABOVE*
Please provide details:
*
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Past Medical History
Cardiorespiratory and metabolic status
Have you had any heart issues?
*
Heart attack / angina
Heart failure / cardiomyopathy
Arrhythmia (e.g. atrial fibrillation, SVT)
Valve disease
Stents
Pacemaker / defibrillator
Open heart surgery
Other
*NONE OF THE ABOVE*
Please provide details:
*
i.e. current and previous symptoms, current and previous treatment
Have you had any lung issues?
*
Asthma
COPD / Emphysema
Bronchiectasis
Other
*NONE OF THE ABOVE*
Please provide details:
*
i.e. current and previous symptoms, current and previous treatment
Have you had any of the following metabolic issues?
*
Sleep apnoea
Type 1 Diabetes
Type 2 Diabetes
High blood pressure
High cholesterol
*NONE OF THE ABOVE*
Please provide details:
*
i.e. current and previous symptoms, current and previous treatment
Do you have any symptoms of sleep apnoea?
*
I snore loudly
I stop breathing at night
I feel sleepy during the day
I suffer from headaches
*NONE OF THE ABOVE*
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Past Medical History
Digestive, internal organs, blood
Do you experience reflux / heartburn / indigestion?
*
Frequently
Occasionally
*NONE OF THE ABOVE*
Do you experience regurgitation or water-brash?
*
Frequently
Occasionally
*NONE OF THE ABOVE*
Have you had any gastrointestinal issues?
*
Hiatus hernia
Inflammatory bowel disease
Irritable bowel syndrome
Coeliac disease
Liver disease (e.g. fatty liver)
Other
*NONE OF THE ABOVE*
Please provide details:
*
i.e. current and previous symptoms, current and previous treatment
Have you had issues with any of the following internal organs?
*
Thyroid
Kidneys
Liver
Adrenal gland
Pancreas
Spleen
*NONE OF THE ABOVE*
Please provide details:
*
i.e. current and previous symptoms, current and previous treatment
Have you had any blood issues?
*
Bleeding
Clotting
Red cell problem
White cell problem
Platelet problem
Other
*NONE OF THE ABOVE*
Please provide details:
*
i.e. current and previous symptoms, current and previous treatment
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Past Medical History
Neurological and mental health status
Have you had any neurological issues?
*
Stroke / mini-stroke / TIA
Epilepsy/seizures
Parkinson's disease
Multiple sclerosis
Restless legs
Other
*NONE OF THE ABOVE*
Please provide details:
*
i.e. current and previous symptoms, current and previous treatment
Have you had any mental health issues?
*
Anxiety
Depression
Bipolar
Schizophrenia
Eating disorder
PTSD
Other
*NONE OF THE ABOVE*
Please provide details:
*
i.e. current and previous symptoms, current and previous treatment
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Past Medical History
Skin, bone, joint, connective tissues
Have you had any joint problems?
*
Osteoarthritis
Rheumatoid arthritis
Psoriatic arthritis
Ankylosing spondylitis
Other
*NONE OF THE ABOVE*
Please provide details:
*
i.e. current and previous symptoms, current and previous treatment
Have you had any autoimmune, inflammatory or connective tissue disease?
*
Lupus
Sjogren's syndrome
Scleroderma / CREST
Polymyalgia
Myasthaenia
Other
*NONE OF THE ABOVE*
Please provide details:
*
i.e. current and previous symptoms, current and previous treatment
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Past Medical History
Other
Have you had any medical problems not listed above?
*
Please provide details:
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Final questions
Do you have any specific questions, concerns or requests?
*
Please provide details:
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