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U.R. No: ________________________________________ Surname: _______________________________________ Given Names: ____________________________________ HISTORY SHEET Date of Birth: ____________________________________
Please fil in if no Bradma Label available If you are under the care of any other Medical Specialists please give details below

Physician __________________________________________ Cardiologist____________________________________
Vascular Doctor _____________________________________ Diabetes Educator ______________________________ Kidney specialist ____________________________________ Other specialist ________________________________ HEALTH AND RISK ASSESSMENT: Do any of the fol owing apply?: If yes please list below
Asthma/Bronchitis
Sleep apnoea/investigative sleep studies Please ensure you bring your CPAP machine to hospital with you
Infection with multi-resistant organism eg golden staph
Please ensure you bring medications to hospital with you
Previous blood clots
Blood thinning medication – Plavix, Cartia, Astrix, Iscover Asasantin, Predaxa, Warfarin
Please ensure you bring medications to hospital with you
Heart attack/heart failure/angina or cardiomyopathy Artificial heart valve/ implant/ defibril ator/ pacemaker
Height: _____________________ cm Weight: _________________ kg BMI
YOUR PHYSICAL HEALTH: Do any of the fol owing apply?: If yes please list below SHEET
High blood pressure
Any other il ness/condition please specify Creutzfeldt-Jacob Disease (CJD) If yes please list below
Have you suffered from a recent rapid progressive dementia,
physical or mental, the cause of which has not been diagnosed? Do you have a family history of 2 or more first-degree relatives with CJD or other undiagnosed neurological il ness? Have you received human pituitary- derived gonadotrophin (for infertility) or growth hormone (for short stature)? Have you received a dura mater graft in a neurological or other surgical procedure before 2990
Other Questions If yes please list below
Do you smoke? If yes, how many per day
What is your daily alcohol intake? Impaired vision SPECIFIC PROCEDURES AND SURGERY If yes please list below

Have you previously had a general anaesthetic
List any reactions below

DISCHARGE PLANNING
Do you have someone to care for you after discharge? Do you have responsibility in caring for others? Do you currently use any community services? Do you require assistance with daily living? Where do you plan to go fol owing discharge? Who is picking you up? ______________________________________ S:\BAYFORMS\Nursing\Patient History Sheet MR 143.Docx MEDICATION SUMMARY
Some medications may need to be ceased prior to surgery and some need to be continued. While you are a patient in our hospital we wil endeavour to ensure that al medications prescribed for you are safe and appropriate. It is important to have an accurate record of all medication that you are already taking. Please complete the fol owing list taking care to include al prescribed, over the counter, herbal and vitamin products. If you have any problems completing the list below please contact your Local Doctor PLEASE BRING TO HOSPITAL A PRINTED LIST OF ALL MEDICATION PRESCRIBED TO YOU BY YOUR DOCTOR AND ALL CURRENT
MEDICATIONS IN THE ORIGINAL PACKAGING IF AVAILABLE
Medication
Strength
Reason for taking?
Taking for how

Medications STOPPED in the past 2 weeks

Medication
Strength
Reason for taking?
When/why
stopped?
In order to ensure an uninterrupted supply of your regular medications during your stay in hospital, please remember to bring ALL your medications in their original labeled containers and/or repeat prescriptions with you upon admission. Please include al
eye drops, patches, natural medicines or topical products Charges for medication provided during your stay in hospital wil be bil ed to your pharmacy account according to the agreement between your Private Health Fund and the Hospital. Not al pharmacy items wil be covered by your health fund. In this case a pharmacy account wil be presented to you on discharge. ALLERGY OR ADVERSE REACTIONS Identify the al ergy: If you have an al ergy describe the
Such as latex, food, skin prep, medication, antiseptic, tapes
and other

The information I have provided here is accurate and complete to the best of my knowledge

Patient signature:
S:\BAYFORMS\Nursing\Patient History Sheet MR 143.Docx

Source: http://thebays.com.au/exfiles/Patient_History_Sheet__2012_MR_143.pdf