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?
Yes No

Do you have a Centrelink Health Care Card?
Yes No

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?
Yes No

Surgery Details
Has your surgery been booked?
Yes No

Proposed date of surgery
Proposed Surgery

Hospital
Surgeon

Surgical and Anaesthetic History

Have you had any operations in the past?
Yes No
Have you had any problems or difficulties with previous anaesthetics?
Yes No
If yes, please give details
If yes, please give details

Have any of your blood relatives had problems with anaesthetics?
Yes No
If yes, please give details

Health Questionnaire

Do you have allergies or adverse reactions?
Yes No

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?
Yes No
Do you have dentures, caps, crowns, bridges, dental implants?
Yes No

If yes, please provide details
If yes, please provide details
Do you have any jaw problems or any difficulty opening your mouth?
Yes No

If yes, please provide details

Heart and Circulation Questions

Do you suffer from High Blood Pressure?
Yes No
Do you suffer from Chest Pain?
Yes No

If yes, please give details
If yes, please give details
Do you suffer from Angina?
Yes No
Have you had a heart attack?
Yes No

If yes, please provide details
If yes, please provide details
Do you suffer from palpitations?
Yes No
Have you suffered from heart failure?
Yes No

If yes, please provide details
If yes, please provide details

Do you have a pacemaker or have you had a valve replacement?
Yes No
Have you had a stroke or mini stroke?
Yes No

If yes, please provide details
If yes, please provide details

Do you suffer from ankle swelling?
Yes No
Have you ever had a blood transfusion?
Yes No

If yes, please provide details
If yes, please provide details

Have you previously had heart surgery?
Yes No
Do you suffer from any other heart condition?
Yes No

If yes, please provide details
If yes, please provide details
Respiratory Questions

Do you smoke or have you ever smoked?
Yes No
Do you suffer from Asthma?
Yes No

If yes, please provide details
If yes, please provide details
Have you been hospitalised for Asthma?
Yes No
Do you regularly use a puffer?
Yes No

If yes, please provide details
If yes, please provide details

Do you suffer from bronchitis or emphysema?
Yes No
Do you snore or have confirmed sleep apnoea?
Yes No

If yes, please provide details
If yes, please provide details

Do you suffer shortness of breath?
Yes No

If yes, please provide details

Other Systems

Do you suffer from Kidney Problems?
Yes No
Do you suffer from Diabetes?
Yes No
If yes, please give details
If yes, is your insulin taken by tablet or diet controlled?

Do you have problems passing urine?
Yes No
Do you suffer from stomach ulcer or hiatus hernia?
Yes No

If yes, please provide details
If yes, please provide details

Do you suffer from Liver disease, hepatitis, jaundice?
Yes No
Do you suffer from Epilepsy?
Yes No

If yes, please provide details
If yes, please provide details

Do you have a thyroid condition?
Yes No
Do you suffer from motion sickness?
Yes No

If yes, please provide details
If yes, please provide details

Do you have an infectious disease?
Yes No
Do you drink alcohol?
Yes No

If yes, please provide details
If yes, please provide details

Medication

Do you regularly take any medication?
Yes No

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?

I acknowledge these details will be saved to form part of my medical records.

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