Anaesthetic Health Questionnaire Step 1 of 9 11% Who will be your Anaesthetist?(Required)Please selectDr Hasher KadavilDr John PrickettDr Steve BruceTo ensure your surgery is not delayed, it is important you click through all pages and submit your information to the anaesthetist as soon as possible.You may have completed similar paperwork to this for your surgeon, or the hospital. Unfortunately, this data is not shared and we do require you to complete this paperwork also. Please allow 15 minutes to complete this questionnaire below in its entirety.Failure to submit this information may result in the cancellation of your surgery if there are unknown health issues that arise on the day of surgery. If you have any questions, please phone our rooms on (02) 4923 8989.Please be advised Dr John Prickett does not require his patients to complete this form. If you have any questions, please phone our rooms on (02) 4923 8989.If you need to see the Doctor in the rooms, please complete the patient information sheet instead.Please be advised Dr Hasher Kadavil does not require his patients to complete this form. If you have any questions, please phone our rooms on (02) 4923 8989.If you need to see the Doctor in the rooms, please complete the patient information sheet instead. About the patient undergoing surgeryPatient name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Patient date of birth(Required) DD slash MM slash YYYY Sex(Required) Male Female Sex refers to the different biological and physiological characteristics of males and females, such as reproductive organs, chromosomes, hormones, etc.Are you the patient?(Required) Yes No Your name(Required)Relationship to the patient(Required)Surgical InformationSurgeon(Required)Please selectDr Andrew YingDr Arvind DeschpandeDr Cameron WhiteDr Jules BurntonDr Scott CairnsDr Nicole OrganSurgeon(Required)Please selectDr Richard HarburyDr Tim WrightSurgeon(Required)Please selectDr John PrickettDr Simon TameDr Steve BruceHospital(Required)Please selectGosford Private HospitalLake Macquarie Private HospitalLingard Private HospitalMaitland Private HospitalRamsay Surgical CentreThe Smile FactoryWarners Bay Private HospitalNewcastle Private HospitalWhat procedure are you having?(Required)Procedure date(Required) DD slash MM slash YYYY Why are you having this operation?(Required)Height (cm)(Required)Weight (kg)(Required)This field is hidden when viewing the formBMI Anaesthetic historyHave you ever had an anaesthetic?(Required) Yes No Have you ever experienced any anaesthetic complications or problems?(Required) Yes No Please list your past procedure names, approximate date of surgery, hospital name and details of any complications.(Required) Patient's Health HistoryHave you been unwell in the 4 weeks leading up to this procedure?(Required) Yes, I have been unwell No, I have had no illness Please provide information(Required)Do you take any weight loss medications?(Required) Yes No Which medication do you take?(Required)Do you take any other regular medications?(Required) Yes No Please list your medication names, dosages and frequency.(Required)If you are unfamiliar with this information, please ask your regular GP to forward a copy of your Patient Health Summary.Do you have any known allergies?(Required) Yes No Please list any allergies and your reactions here. (i.e. "Allergy 1 - " "Allergy 2 - ")(Required) Social FactorsDo you smoke/vape?(Required) No Yes, I smoke Yes, I vape Yes, I smoke and vape How many cigarettes do you smoke per day?(Required)How long have you been smoking?(Required)How long have you been vaping?(Required)Were you a smoker before you started vaping?(Required) Yes No How long were you a smoker for? And how many cigarettes did you smoke per day?(Required)Do you regularly drink alcohol?(Required) Yes - I consume alcohol 4-7 days per week Yes - I consume alcohol 1-3 days per week Yes - I consume alcohol infrequently No - I do not drink alcohol at all How much alcohol would you typically consume when you are drinking?(Required) Do you have, or have you ever had, any of the following?Diabetes(Required) Yes No Diabetes type(Required) Type 1 Type 2 Gestational (current) Gestational (previous, now resolved) Other How is your diabetes managed?(Required) Insulin Tablets Diet Other If you use insulin, at what blood glucose level (BGL) would you start to get symptoms of a 'hypo'?(Required)Any trouble with your heart or cardiovascular system, or have you ever been to a Cardiologist?(Required) No Yes Yes, but I have not seen a cardiologist Who is your Cardiologist? What suburb are they located?(Required)Please select any that apply(Required) Arrhythmia (irregular heartbeat) Atrial fibrilation (rapid, irregular heartbeat) Congenital heart disease (present from birth) Coronary heart disease Experienced cardiac arrest Hypertension Ischemic heart disease Valvular heart disease Unsure, cannot recall Other Please provide details here.(Required)Shortness of breath climbing less than 2 flights of stairs or whilst walking for 30 minutes on flat ground?(Required) Yes No Any trouble with your lungs or respiratory system, or have you ever seen a Respiratory/Sleep specialist?(Required) No Yes Yes, but I have not seen a Respiratory/Sleep specialist? Who is your Respiratory/Sleep specialist? What suburb are they located?(Required)Please select any that apply(Required) Asthma Chronic obstuctive pulmonary disease (COPD) Obstructive sleep apnea (OSA) Other Please provide details here.(Required)Have you been recommended to use a CPAP machine?(Required) Yes No Do you have a CPAP machine?(Required) Yes No Please provide more details.(Required)Gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia, or have you had gastric surgery?(Required) Yes No If yes, please provide details of symptoms/any procedural information.(Required)Thyroid disease?(Required) Yes No Please select all that apply;(Required) Your thyroid hormone levels are normal Your last blood test was within 12 months Your last blood test was NOT within 12 months Your breathing becomes difficult when lying flat Do you have an enlarged thyroid gland, otherwise called a goitre?(Required) Yes No What is your thyroid diagnosis?(Required)Who is you Endocrinologist? What suburb are they located?(Required)Neurological Condition?(Required) Yes No Please provide details(Required)Rheumatoid arthritis, connective tissue disease or any other musculoskeletal issues?(Required) Yes No Please provide details(Required)Kidney condition?(Required) Yes No Please provide details(Required)Blood clots or excessive bleeding?(Required) Yes No Please provide details(Required)Cancer?(Required) Yes No Please provide details(Required)Is there a chance you could be pregnant?(Required) Yes No How many weeks are you/would you be today?(Required) Other health informationHave you ever had COVID-19?(Required) Yes No Have you had COVID-19 in the last 4 weeks?(Required) Yes No Which of the following describes your mouth, teeth, and dentition?(Required) I have my own teeth only (with or without fillings) Loose tooth or teeth Chipped tooth or teeth Caps, crowns, implants or veneers Dentures I am unable to open my mouth fully Please indicate the pain relievers or analgesics that have worked well for you previously(Required) Paracetamol, eg. Panadol, Dymadon Paracetamol-codeine combinations, eg. Panadeine Forte, Painstop Anti-inflammatories, eg. Nurofen, Voltaren, Celebrex, Mobic Tramadol, eg. Tramal Tapentadol, eg. Palexia Strong opioids, eg. OxyNorm, Endone, Targin, Sevredol Are there any pain relievers or analgesics that you must avoid or should not use?(Required) Yes No Which pain relievers or analgesics should be avoided? Why?(Required)Are there any other medical issues not mentioned already that should be?(Required) Yes No Please provide as much detail as possible.(Required) Family historyTo your knowledge, have any of your blood relatives experienced a severe reaction to an anaesthetic?(Required) Yes No Please provide details of their relationship to you, and details of the reaction.(Required)To your knowledge, have any of your blood relatives experienced any significant health issues that we should be aware of? (i.e. heart, etc.)(Required) Yes No Please provide details of their relationship to you, and further details.(Required) We need your consentDo you give your consent for me to contact your other doctors and access your medical records if required?(Required) Yes No Do you have My Health Record?(Required) Yes, I consent to your access of my record. Yes, I do NOT consent to your access of my record. No Would you like to be contacted by your Anaesthetist prior to your procedure?(Required) Yes No Only if the anaesthetist has any specific issues they wish to discuss What questions do you have for the anaesthetist?(Required)How would you like to be contacted?(Required) Telephone Email What is your contact number?(Required)What is your email address?(Required)Is there anything else you would like to mention?(Required) Yes No Please use the field below to communicate with your anaesthetist.(Required)Patient Acknowledgement and Consent(Required) All information provided here is accurate at time of completion. I understand that if I have supplied misleading information, this may result in the cancellation of my procedure on the day of operation.Signature(Required)This form was signed by(Required) The patient Someone other than the patient Please supply your email address to receive a copy of this completed form.(Required) Return to Home Page Patient Information Sheet Contact Us
