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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
PAEDIATRIC 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 Health History
YOUR DETAILS
CHILD'S NAME
*
PLANNED OPERATION
*
PARENT'S NAME
*
PARENT'S EMAIL
*
PARENT'S PHONE
*
CHILD'S DATE OF BIRTH
*
DD slash MM slash YYYY
FULL TERM BABY
*
PLEASE BRIEFLY OUTLINE THE REASON FOR THE OPERATION
*
WEIGHT
*
HEIGHT
*
GENERAL HEALTH HISTORY
Any respiratory conditions?
*
None
Asthma
Chronic Cough
Bronchitis
Obstructive Sleep Apnoea
Other
Other respiratory conditions
*
Any heart conditions?
*
None
Benign Heart Murmur
Valve Abnormality
Hole in the Heart
Other
Other heart conditions
*
Any family history of inherited medical conditions?
*
Yes
No
Other family history conditions
*
Any family history of anaesthetic complications?
*
Yes
No
Please provide info
*
Does your child regularly take any medications?
*
Yes
No
Please detail the medication and dosage
*
Does your child have any allergies?
Yes
No
Please detail their allergies
*
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, please enter your surgeon's name
Anything you want to tell the anaesthetist?
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