East Coast Anaesthetic Practice | Gold Coast Anaesthetic
PATIENT NAME *
PATIENT DATE OF BIRTH *
Your Name *
Your Email *
Your Phone Number *
Type of operation you are having *
Surgical item numbers
Date of operation
Which healthfund are you in? *
Who is your Anaesthetist? *
Who is your Surgeon?
Which hospital?
Type of operation
Approximate date
Hospital
Have you previously had any problems with anaesthetics? If yes, provide details below
What is your height in metres (m)?
What is your weight in kilograms (kg)?
BMI Result Do you or your family have history of problems or reactions with anaesthetics? YesNo
No Heart HistoryIrregular Heart BeatIschaemic Heart Disease (e.g "Heart attack"...Heart FailureHigh Blood PressureHeart Valve abnormalityHad a stent or Bypass in the past OtherOther
Please provide details of the heart condition above
Do you have Sleep apnoea? YesNo
Do you have a CPAP machine? YesNo
Do you have Kidney Disease? YesNo
Gastrointestinal Disease (eg reflux, stomach ulcer, crohns disease, other)? YesNo
Neurological History (stroke, TIA, dementia, epilepsy, parkinsons disease)? YesNo
Do you have Diabetes? Yes, I'm insulin dependantYes, I'm non insulin dependant (i.e. on tablet...No
Do you have vascular Disease (blocked arteries or clots in the leg)? YesNo
Do you have a blood disorder? YesNo
Please provide details of any other medical condition not mentioned so far:
Name
Area of specialisation
Phone Number
Have you had any Blood tests or other Investigations done recently? YesNo
Please provide the details
Are you currently taking any medications (including over the counter and herbal medications)? YesNo
Do you smoke or vape? YesNo
How many cigarettes per day?
Do you drink alcohol? YesNo
Please detail which recreational drugs you take
Do you regularly exercise? YesNo
What type of exercise?
Have you had a look at the information sheets on this website relevant to your or your child's operation? YesNo
Do you have any other concerns or questions about your anaesthetic?
