Pre-op Anesthetic Assessment Form

Pre-op Anesthetic Assessment Form
Personal details
Name*
First NameLast Name
Date of Birth*
DayMonthYear
Sex*
Email address*
example@example.com
Phone Number
Please enter a valid phone number.
Height*
Weight*
Are you filling out this form for yourself?*
Helper's details
Name*
First NameLast Name
Relationship to patient*
e.g. parent, daughter/son, friend
Phone Number (if different)
Please enter a valid phone number.

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?*

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?*

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 anaestheticSpinal/epidural anaestheticLocal anaestheticSedationNot sure
Have you ever had problems with an anaesthetic?*
Inadequate pain reliefNausea or vomitingDifficult veinsDifficult breathing tubeDrug reactionAwarenessOther*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 toothI have missing teethI have had dental workI have dentures*NONE OF THE ABOVE*
Please provide details:*

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)

Substance use
Smoking history*
Current smokerFormer smoker*NEVER*
For how many years have you smoked?*
< 1 year1-10 years10-20 years20-40 years> 40 years
How many cigarettes do you smoke on an average day?*
< 5 per day5-10 per day10-20 per day20-40 per day> 40 per day
How long ago did you quit smoking?*
< 1 month ago1-6 months ago> 6 months ago
For how many years did you smoke?*
< 1 year1-10 years10-20 years20-40 years> 40 years
How many cigarettes did you smoke on an average day?*
0-5 per day5-10 per day10-20 per day20-40 per day> 40 per day
Alcohol history*
Most daysOccasionallyRarely*NEVER*
Please describe your typical daily intake of alcohol:*

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 testECG (heart electrical trace)Echocardiogram (heart ultrasound)Lung function testSleep studies*NONE OF THE ABOVE*
Please provide details:*
i.e. location, date, result (if known)

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 hillsNormal childhood activity (e.g. playground)Physical work as part of my jobPhysical work around the houseWalking outsideWalking insideUnable to walkOther
Please provide details:*
i.e. location, date, result (if known)
Have you had any of the following symptoms in the past week?*
Chest painDizziness / fainting / collapseBreathlessness with ordinary activityBreathlessness at restBreathlessness when lying flat*NONE OF THE ABOVE*
Please provide details:*
Have you had any respiratory illnesses in the past week?*
Runny noseSore throatDry coughChesty coughFever*NONE OF THE ABOVE*
Please provide details:*

Past Medical History
Cardiorespiratory and metabolic status
Have you had any heart issues?*
Heart attack / anginaHeart failure / cardiomyopathyArrhythmia (e.g. atrial fibrillation, SVT)Valve diseaseStentsPacemaker / defibrillatorOpen heart surgeryOther*NONE OF THE ABOVE*
Please provide details:*
i.e. current and previous symptoms, current and previous treatment
Have you had any lung issues?*
AsthmaCOPD / EmphysemaBronchiectasisOther*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 apnoeaType 1 DiabetesType 2 DiabetesHigh blood pressureHigh 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 loudlyI stop breathing at nightI feel sleepy during the dayI suffer from headaches*NONE OF THE ABOVE*

Past Medical History
Digestive, internal organs, blood
Do you experience reflux / heartburn / indigestion?*
FrequentlyOccasionally*NONE OF THE ABOVE*
Do you experience regurgitation or water-brash?*
FrequentlyOccasionally*NONE OF THE ABOVE*
Have you had any gastrointestinal issues?*
Hiatus herniaInflammatory bowel diseaseIrritable bowel syndromeCoeliac diseaseLiver 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?*
ThyroidKidneysLiverAdrenal glandPancreasSpleen*NONE OF THE ABOVE*
Please provide details:*
i.e. current and previous symptoms, current and previous treatment
Have you had any blood issues?*
BleedingClottingRed cell problemWhite cell problemPlatelet problemOther*NONE OF THE ABOVE*
Please provide details:*
i.e. current and previous symptoms, current and previous treatment

Past Medical History
Neurological and mental health status
Have you had any neurological issues?*
Stroke / mini-stroke / TIAEpilepsy/seizuresParkinson's diseaseMultiple sclerosisRestless legsOther*NONE OF THE ABOVE*
Please provide details:*
i.e. current and previous symptoms, current and previous treatment
Have you had any mental health issues?*
AnxietyDepressionBipolarSchizophreniaEating disorderPTSDOther*NONE OF THE ABOVE*
Please provide details:*
i.e. current and previous symptoms, current and previous treatment

Past Medical History
Skin, bone, joint, connective tissues
Have you had any joint problems?*
OsteoarthritisRheumatoid arthritisPsoriatic arthritisAnkylosing spondylitisOther*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?*
LupusSjogren's syndromeScleroderma / CRESTPolymyalgiaMyasthaeniaOther*NONE OF THE ABOVE*
Please provide details:*
i.e. current and previous symptoms, current and previous treatment

Past Medical History
Other
Have you had any medical problems not listed above?*
Please provide details:

Final questions
Do you have any specific questions, concerns or requests?*
Please provide details:
Should be Empty: