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INFORMATION REGARDING COVID-19
Pre-op Questionnaire
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Dr Matthew Griffiths
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Home
About Us
Dr Kirsten Morgan
Dr Matthew Griffiths
Patient Resources
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Fees & Quote
Pre-Op Questionnaire
Patient Survey
Who we work with
Surgeons
Accredited Hospitals
Contact us
Home
About Us
Dr Kirsten Morgan
Dr Matthew Griffiths
Patient Resources
Infosheets
FAQs
Fees & Quote
Pre-Op Questionnaire
Patient Survey
Who we work with
Surgeons
Accredited Hospitals
Contact us
Home
About Us
Dr Kirsten Morgan
Dr Matthew Griffiths
Patient Resources
Infosheets
FAQs
Fees & Quote
Pre-Op Questionnaire
Patient Survey
Who we work with
Surgeons
Accredited Hospitals
Contact us
Adult pre-op Questionnaire
So that we can plan the best medical care please fill out this questionnaire and submit to your Anaesthetist.
1
Your Details
2
Your Procedure
3
Your Health History
YOUR DETAILS
PATIENT NAME
*
PATIENT DATE OF BIRTH
*
DD slash MM slash YYYY
YOUR NAME
*
YOUR EMAIL
*
YOUR PHONE NUMBER
*
ABOUT YOUR PROCEEDURE
Type of operation you are having
*
Surgical item numbers
*
Date of operation
DD slash MM slash YYYY
Which healthfund are you in?
*
Who is your Anaesthetist?
*
Dr Kirsten Morgan
Dr Matthew Griffiths
Who is your Surgeon?
Please select
Ahn
Donnellan
Gellert
Kong
O’Hara
Pang
Patel
Sandercoe
Soma
Ting
Other
Other Surgeon
Which hospital?
Please select
Castlecrag Hospital
Double Bay Day Hospital
HSS Hospital for Specialist Services
Hunters Hill Private Hospital
Macquarie Private Hospital
Macquarie University Hospital
North Shore Private
Norwest Private Hospital
Prince of Wales Private
Sydney Adventist Hospital
Other
Other hospital
Previous operations
Type of operation
Approximate date
Hospital
Please detail all proceedures. You can add extra rows by clicking the [ + ] icon to the right.
Have you previously had any problems with anaesthetics? If yes, provide details below
GENERAL HEALTH HISTORY
What is your height in metres (m)?
What is your weight in kilograms (kg)?
BMI Result
This field is hidden when viewing the form
Do you have a family history of heart disease?
Yes
No
This field is hidden when viewing the form
Do you have a family history of diabetes?
Yes
No
Do you or your family have history of problems or reactions with anaesthetics?
Yes
No
Heart History
*
No Heart History
High Blood Pressure
Irregular Heart Beat
Heart Valve abnormality
Ischaemic Heart Disease (e.g “Heart attack” “angina” )
Had a stent or Bypass in the past
Heart Failure
Other
Respiratory History (Lungs)
*
No Respiratory History
Bronchitis
Pulmonary embolus
Asthma
Emphysema, CAL or COPD
Recent Chest infection
Other
Please provide details of the heart condition above
Do you have Sleep apnoea?
Yes
No
Do you have a CPAP machine?
Yes
No
Do you have Kidney Disease?
Yes
No
Gastrointestinal Disease (eg reflux, stomach ulcer, crohns disease, other)?
Yes
No
Neurological History (stroke, TIA, dementia,epilepsy, parkinsons disease)?
Yes
No
Do you have Diabetes?
Yes, I'm insulin dependant
Yes, I'm non insulin dependant (i.e. on tablets or diet controlled)
No
Do you have vascular Disease (blocked arteries or clots in the leg)?
Yes
No
Do you have a blood disorder?
Yes
No
Please provide details of any other medical condition not mentioned so far:
Do you have any other specialists looking after your health?
Name
Area of specialisation
Phone number
Please detail all specialists. You can add extra rows by clicking the [ + ] icon to the right.
Have you had any Blood tests or other Investigations done recently?
Yes
No
Please provide the details
Are you currently taking any medications (including over the counter and herbal medications)?
Name
Frequency
Please detail all medications. You can add extra rows by clicking the [ + ] icon to the right.
Are you taking any weight loss medication such as Ozempic?
Yes
No
Do you smoke or vape?
Yes
No
How many cigarettes per day?
Do you drink alcohol?
Yes
No
How many standard drinks per day on average?
Do you take recreational drugs?
Yes
No
Please detail which recreational drugs you take
Do you regularly exercise?
Yes
No
What type of exercise?
Have you had a look at the information sheets on this website relevant to your or your child’s operation?
Yes
No
15. Do you have any other concerns or questions about your anaesthetic?
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