Patient Pre-Op Information Form

Every patient is different and as a result, so too, will be the requirements for your anaesthetic. In order for Dr Goonan to plan your anaesthetic, it would be of great assistance and if you could complete the following questionnaire about your current health status and your medical history.

Please have your Medicare card and health fund details at the ready, as the questionnaire will timeout after 30 minutes.

All information will be treated in the strictest confidence and only available to third parties if you have given your consent.

  • Personal Details
  • Title
  • Given Name *
  • Surname *
  • Gender *
  • Date of Birth *
  • (yyyy)
  • Occupation
    If retired, previous occupation.
  • Contact Details
  • Street Address *
  • Suburb *
  • State *
  • Postcode *
  • Phone Number *
  • Mobile Number
  • Email address *
  • Medicare Details
  • Medicare Number
  • Reference Number
  • Expiry Date
    (mm/yyyy)
  • Health Insurance Details
  • Do you have Private Health Insurance?
         
  • Do you have a Centrelink Health Care Card?
         
  • Name of Health Fund
  • Membership Number
  • Level of Cover
  • DVA Card Type
  • DVA Number
  • General Practitioner
  • Doctors Name
  • Doctors Contact Number
  • Do you consent to me contacting them to discuss details of your medical history?
         
  • Surgery Details
  • Has your surgery been booked?
         
  • Proposed date of surgery
  • Proposed Surgery
  • Hospital
  • Surgeon
  • Surgical and Anaesthetic History
  • Have you had any operations in the past?
         
  • Have you had any problems or difficulties with previous anaesthetics?
         
  • If yes, please give details
  • If yes, please give details
  • Have any of your blood relatives had problems with anaesthetics?
         
  • If yes, please give details
  • Health Questionnaire
  • Do you have allergies or adverse reactions?
         
  • If yes, please provide details
    e.g. latex, iodine, seafood, eggs, adhesive tapes, x-ray dyes etc.
  • What is your height? *
    cm
  • What is your weight *
    kg
  • Airway Questions
  • Do you have any loose or chipped teeth?
         
  • Do you have dentures, caps, crowns, bridges, dental implants?
         
  • If yes, please provide details
  • If yes, please provide details
  • Do you have any jaw problems or any difficulty opening your mouth?
         
  • If yes, please provide details
  • Heart and Circulation Questions
  • Do you suffer from High Blood Pressure?
         
  • Do you suffer from Chest Pain?
         
  • If yes, please give details
  • If yes, please give details
  • Do you suffer from Angina?
         
  • Have you had a heart attack?
         
  • If yes, please provide details
  • If yes, please provide details
  • Do you suffer from palpitations?
         
  • Have you suffered from heart failure?
         
  • If yes, please provide details
  • If yes, please provide details
  • Do you have a pacemaker or have you had a valve replacement?
         
  • Have you had a stroke or mini stroke?
         
  • If yes, please provide details
  • If yes, please provide details
  • Do you suffer from ankle swelling?
         
  • Have you ever had a blood transfusion?
         
  • If yes, please provide details
  • If yes, please provide details
  • Have you previously had heart surgery?
         
  • Do you suffer from any other heart condition?
         
  • If yes, please provide details
  • If yes, please provide details
  • Respiratory Questions
  • Do you smoke or have you ever smoked?
         
  • Do you suffer from Asthma?
         
  • If yes, please provide details
  • If yes, please provide details
  • Have you been hospitalised for Asthma?
         
  • Do you regularly use a puffer?
         
  • If yes, please provide details
  • If yes, please provide details
  • Do you suffer from bronchitis or emphysema?
         
  • Do you snore or have confirmed sleep apnoea?
         
  • If yes, please provide details
  • If yes, please provide details
  • Do you suffer shortness of breath?
         
  • If yes, please provide details
  • Other Systems
  • Do you suffer from Kidney Problems?
         
  • Do you suffer from Diabetes?
         
  • If yes, please give details
  • If yes, is your insulin taken by tablet or diet controlled?
  • Do you have problems passing urine?
         
  • Do you suffer from stomach ulcer or hiatus hernia?
         
  • If yes, please provide details
  • If yes, please provide details
  • Do you suffer from Liver disease, hepatitis, jaundice?
         
  • Do you suffer from Epilepsy?
         
  • If yes, please provide details
  • If yes, please provide details
  • Do you have a thyroid condition?
         
  • Do you suffer from motion sickness?
         
  • If yes, please provide details
  • If yes, please provide details
  • Do you have an infectious disease?
         
  • Do you drink alcohol?
         
  • If yes, please provide details
  • If yes, please provide details
  • Medication
  • Do you regularly take any medication?
         
  • Medication
  • Dosage
  • Times Daily
  • Please provide any further information on your medications
    Includes over the counter medication, herbal supplements, fish oils, vitamins, etc.
  • Further Information
  • Emergency contact person
  • Relationship
  • Contact person's phone number
  • Contact person's mobile phone number
  • Are there any other details that you think I should know?
  •   
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