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Preoperative Assessment Questionnaire

Image preop assessment.docx

 

PRE OPERATIVE ASSESSMENT

TO BE COMPLETED BY ASSESSMENT STAFF

Proposed Procedure:

 

Blood Pressure:

 

 

Have you had any sudden unexplained weight loss

  Yes

  No

Pulse:

 

 

 

02 Saturation

 

Are you or could you be pregnant?

 

 

Height:

 

Date of LMP:                

 

Weight:

 

Contraceptive pill/implant/injection?

Details:

 

 

 

 

BMI:

 

Current Medication:

 

Essential criteria for day surgery admission:

Yes

No

Are you willing to undergo the proposed procedure as a day patient?

 

 

Be able to be driven home by car or taxi?

 

 

Have a responsible adult to take you home and stay with you for 24 hours?

 

 

Have immediate access to a telephone?

 

 

Have easy access to your home/toilet?

 

 

Stay within 60 minutes drive of the hospital?

 

 

                                                                               

Have you ever suffered from any of the following?

 Yes

  No

Chest pain on exertion or at night?

 

 

Breathlessness or shortness of breath?

 

 

Asthma, bronchitis, COPD or a wheeze?

 

 

Do you or have you recently had a cough or cold?

 

 

High Blood Pressure?

 

 

Heart problems, angina, heart murmur/rheumatic fever?

 

 

Fainting easily/dizzy spells?

 

 

Epilepsy, convulsions or fits?

 

 

Anaemia or other blood problems e.g. Von Willebrands/Sickle Cell?

 

 

Excessive bleeding or bruising?

 

 

Deep vein thrombosis, pulmonary embolus or stroke?

 

 

Kidney or urinary problems?

 

 

Bowel problems?

 

 

Indigestion, heartburn, hiatus hernia or stomach ulcer?

 

 

Diabetes?  ­­­­­­­­­­­­­­­­­­

 

 

Do You?

Yes

No

Drink more than 1.5 pints of beer or 3 shorts per day?

Approximate weekly units: ____________________

 

 

Smoke: if yes how many packs/tobacco a day? ________________

    

 

Take any medication or herbal remedies?[not already listed]

[tablets, inhalers, creams or patches]

 

 

Do you currently or have you used intravenous or recreational drugs?

Details:  __________________________________________­­­­­­

 

 

Have you taken any steroids medication in the last 2 years?

Details:  __________________________________________

 

 

 

Have you ever had?

Yes

No

An allergic reaction to anaesthetics, medicines, creams, elastoplasts, latex or metal?

Details:  _____________________________________________________

 

 

A serious illness?

E.G. Cancer, TB, Meningitis, Thyroid, Jaundice, Hepatitis or HIV.

Details:  _____________________________________________________

 

 

Muscle disease or progressive weakness?

 

 

Arthritic or mobility problems?

 

 

List previous operations:                                               

                                                              

 

Anaesthetic or surgical complications:                                                 Date of last anaesthetic:  

 

 

Any family history of general anaesthetic problems?

Details:

 

Do you have any prostheses or implants?

Yes

No

Dental:

 

 

 

Hearing Aid:

 

 

 

Ophthalmic:

 

 

 

Cardiac:

 

 

 

Other:

 

 

 

Date of investigations/blood requests:

CXR

 

ECG

 

Pregnancy Test

 

FBC

 

Amylase

 

BM/Glucose

 

U & E’s

 

TFT’s

 

Coagulation Screen

 

LFT’s

 

Calcium/Bone

 

INR/PIT

 

Full Screen

 

Group & Screen

 

Therapeutic Drug

 

Other:

Summary of patient’s health status:

 

 

 

 

 

 

 

 

 

I agree that the information I have provided at the assessment to be accurate and correct.

I confirm that I have received both verbal and written information from assessment staff

I understand that there may prolonged effects from anaesthetics which make it unsafe for me to drive, operate any form of machinery, drink alcohol or make important decisions for 24 hrs following a general anaesthetic.

Signature Patient/ Parent/ Guardian:  ______________________________

Signature of Assessment Nurse:         _______________________________

Date:  _________________