Ph: 07 41282550, 127 Torquay Rd Scarness QLD 4655

Patient Questionnaire

Please take your time to complete this Patient Questionnaire. It is important that you complete this questionnaire as accurately as possible for consideration by your Anaesthetist, prior to your appointment. If you are unsure of any information, please contact our staff as AnaCare between 9-3.00pm weekdays on (07) 4128 2550 for assistance.

When you have completed the form, simply press the Submit Form button at the bottom of the questionnaire and it will be automatically submitted to AnaCare.

Pre-Operative Assessment Questionnaire

Patient Name:

Address:

Suburb:

State:

Postcode:

Email:

Home phone:

Work phone:

Mobile phone:

Your date of birth:

GP's name:

GP's phone:

Surgeon's name:

Surgeon's phone:

Name of operation:

Date of operation:

Medicare number:

Private health fund name:

Private health fund number:

Current medications: Please list ALL medications you are currently taking (including over the counter, herbal/alternative medicines and/or pain killers). State dosage and strength. Click here to write.

Previous operations: Please list ALL previous operations including approximate dates. Click here to write.

Have you, or a relative had any complications with an anaesthetic or operations? Yes No If yes, please give details of previous complications here. Click here to write.

Do you have any allergies to medications, latex, rubber and/or tropical fruits?

Yes No

Do you currently have, or have ever had, any of the following conditions?
(please tick all that apply)

Cardio Vascular Disease:

Respiratory Disease:

Blood Disease:

Anaemia

Haemophilia

Bruising Problems

Blood Disease/Bleeding

Blood Clot in the legs or lungs (Thrombosis or Embolism)

Have you taken any of these within the past 5 days:

Central Nervous System Disease:

Gastro Intestinal Disease:

Endocrinal Disease:

Diabetes with Insulin treatment

Diabetes with tablet treatment

Diabetes managed by diet

Muscular Skeletal Disease:

Arthritis

Muscle Disease

Please answer the following yes/no questions:

Do you take Hormone Replacement Therapy? Yes No If yes, please give details here. Click here to write.

Do you smoke? Yes No If yes, please give details of how many per day. Click here to write.

Have you ever smoked? Yes No If yes, when did you stop? Please give details here. Click here to write.

Do you use recreational drugs? Yes No If yes, which drugs and how often? Please give details here. Click here to write.

Do you consume Alcohol? Yes No If yes, please give details of how much and how often here. Click here to write.

Have you lost weight recently without trying? Yes No If yes, how much weight? Please give details here. Click here to write.

Have you been eating poorly because of a decreased appetite? Yes No

Are there any other health problems of which your Anaesthetist should be aware of? Yes No If yes, please give details here. Click here to write.

How much do you weigh?

How tall are you?

Do you wear or have any of the following (please tick):

Have you had Anaesthetic by Dr Adel Tanious before? Yes No

By checking this box I declare that the information I have supplied in this
questionnaire is accurate to the best of my knowledge: