Microsoft word - pre-op health questionnaire.doc
NORTHSIDE ANAESTHESIA
PRE-OPERATIVE ASSESSMENT QUESTIONNAIRE
Please
complete and
return as soon as possible. Circle appropriate answer.
Surname: ____________________________________
Given Names ___________________________________________
Address: ___________________________________________________________________________________Post code: _______
Phone: (H) (_____) _____________________
(W) (_____) ___________________ (Fax) (_____) _________________
Other contact details: ________________________________________________________________________________________
Proposed Operation or Procedure:______________________________________________________________________________
Operation Date: _______________________________
Admit Date: _________________________________
Surgeon’s Name: _______________________________
Hospital:_____________________________________
Who will be your next of kin, partner, parent, guardian or other
responsible person for contact purposes?
Name: _______________________________________________ Phone: (H) (___) ________________ (W) (___) ______________
Do you have any language or other
communication difficulties?
(Details: ________________________________________________________________________________________)
What is your approximate
weight: ___________ kgs and height: ___________ metres
PAST SURGICAL HISTORY
Have you ever had an operation before?
If “Yes” please give details _____________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
ANAESTHETICS
Have you had any
anaesthetics?
Have you had any
problems or difficulties with anaesthetics?
Do you have blood relatives with anaesthetic problems?
(details:_____________________________________________________________________________________________________
___________________________________________________________________________________________________________
CARDIOVASCULAR SYSTEM
If “Yes” have you ever been hospitalised because of it?
Details: _____________________________________________________________________________________________________
___________________________________________________________________________________________________________
RESPIRATORY SYSTEM
(If so, have you ever been hospitalised because of it?)
(Or have you ever required steroids (prednisone) to treat it?)
Can you lie flat and level (with one pillow)?
Can you walk up 12 stairs without stopping due to
breathlessness? Yes No
Do you smoke or did you previously smoke?
No (If yes - how much______ how many_____)
PATIENT SURNAME ______________________ GIVEN NAMES________________________
OTHER SYSTEMS
Heartburn, reflux or hiatus hernia? Yes
Diabetes (is it controlled by diet: tablets: insulin)?
Infectious diseases (hepatitis; HIV; AIDS etc.)?
Blood clots in the leg (DVT) or in the lung
Drugs to thin the blood (warfarin: aspirin etc.)?
Is it possible that you are
pregnant? n/a
(if yes – how much? __________________) Have you ever had a blood transfusion?
Are there any other facts about your health or medical
conditions that you believe I should know about in order to
If “Yes” please give details _____________________________________________________________________________________
___________________________________________________________________________________________________________
MEDICATIONS Are you taking
any medications?
(details_____________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
ALLERGIES & ADVERSE REACTIONS
Have you any
allergies or adverse reactions?
(details:_____________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
(e.g. Do you have problems with seafood, eggs, peanuts, iodine, sticky tapes, or x-ray dyes?)
Any chipped or loose
teeth?
Dentures, caps, bridges, crowns of any kind?
Any jaw problems or trouble opening your mouth?
(details:_____________________________________________________________________________________________________
___________________________________________________________________________________________________________
RECENT INVESTIGATION Have you recently had any tests?
Blood tests (Which Lab? S&N / QML / other ____________ ) Yes
Chest x-ray (where: ______________________________ ) Yes
ECG, Echocardiograph, or Stress test (where :_____________ )
Lung function tests (where: ___________________________ ) Yes
Who is your usual
GP? ___________________________________________________Ph: (_____) __________________________
Do you mind if I contact them to discuss details of your medical history
Are there
any other relevant details or requests you wish to add?
______________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature of patient, parent or guardian: _________________________________ Date: ___________________
Return to
Northside Anaesthesia, Suite 20, Level 2 Holy Spirit Northside, 627 Road, Chermside 4032
or Fax to (07) 3359 7022
Source: http://www.northsideanaesthesia.com.au/documents/Pre-op%20Health%20Questionnaire.pdf
Ain Shams Journal of Anesthesiology Vol 5-1; Jan 2012 DEXAMETHASONE AS ADJUVANT TO CAUDAL ROPIVACAINE AS ANALGESIC FOR LABOR PAIN Ahmed Abdalla Mohammed1, Wael Ahmed Ibrahim2 , Tamer Fayez Safan1 1 Department of Anesthesiology, Cairo University , Cairo, Egypt 2 Department of Anesthesiology, NCI, Cairo University , Cairo, Egypt Abstract Objectives : To evaluate analges
Tel: +31 (0)320 29 69 69 Postal account: 1414592The column 'HM' shows if an article is, in general, available with a 'Distributed by Holden Medical' label. Sometimes we also carry manufacturer's label for the same product. If you specifically require the product with a 'Distributed by Holden Medical' label, please specify this in your order/request. Otherwise it might be supplied with another l