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Patient Pre-Op Information Form

Patient Pre-Op Information Form

Every patient is different and as a result, so too, will be the requirements for your anaesthetic. In order for Dr Goonan to plan your anaesthetic, it would be of great assistance and if you could complete the following questionnaire about your current health status and your medical history.

All information will be treated in the strictest confidence and only available to third parties if you have given your consent.

**PLEASE NOTE - If you have had COVID recently or within 8 weeks of your procedure, please notify Dr Goonan or your surgeon to discuss your procedure**

 

Personal Details

If retired, previous occupation.

Contact Details

Medicare Details

Health Insurance Details

Do you have Private Health Insurance?
Do you have a Centrelink Health Care Card?

General Practitioner

Do you consent to me contacting them to discuss details of your medical history?

Surgery Details

Has your surgery been booked?

Surgical and Anaesthetic History

Have you had any operations in the past?
Have you had any problems or difficulties with previous anaesthetics?
Have any of your blood relatives had problems with anaesthetics?

Health Questionnaire

Do you have allergies or adverse reactions?
e.g. latex, iodine, seafood, eggs, adhesive tapes, x-ray dyes etc.
cm
kg

Airway Questions

Do you have any loose or chipped teeth?
Do you have dentures, caps, crowns, bridges, dental implants?
Do you have any jaw problems or any difficulty opening your mouth?

Heart and Circulation Questions

Do you suffer from High Blood Pressure?
Do you suffer from Angina?
Do you suffer from palpitations?
Do you have a pacemaker or have you had a valve replacement?
Do you suffer from ankle swelling?
Have you previously had heart surgery?
Do you suffer from Chest Pain?
Have you had a heart attack?
Have you suffered from heart failure?
Have you had a stroke or mini stroke?
Have you ever had a blood transfusion?
Do you suffer from any other heart condition?

Respiratory Questions

Do you smoke or have you ever smoked?
Have you been hospitalised for Asthma?
Do you suffer from bronchitis or emphysema?
Do you suffer shortness of breath?
Do you suffer from Asthma?
Do you regularly use a puffer?
Do you snore or have confirmed sleep apnoea?

Other Systems

Do you suffer from Kidney Problems?
Do you have problems passing urine?
Do you suffer from Liver disease, hepatitis, jaundice?
Do you have a thyroid condition?
Do you have an infectious disease?
Do you suffer from Diabetes?
Do you suffer from stomach ulcer or hiatus hernia?
Do you suffer from Epilepsy?
Do you suffer from motion sickness?
Do you drink alcohol?

Medication

Do you regularly take any medication?
Includes over the counter medication, herbal supplements, fish oils, vitamins, etc.

Further Information

I acknowledge these details will be saved to form part of my medical records.
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Menai, NSW 2234

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