Elite Surgical Pre Operative Questionnaire 2

Patient Information

Title:

First Name:

Last Name:

Patient Address

Street Address:

Address Line 2:

City:

Post Code:

Country:

Phone Number:

Patient Date of Birth:

Age:

Gender:

Email:

Next of Kin (Emergency Contact)

Name:

Relationship:

Contact Number:

Are you happy for this person to be contacted about your treatment?*:

Are you registered with a GP?

GP Details

Name of GP & Practice (NA if not applicable):

Full Address (NA if not applicable):

Contact number (NA if not applicable):

GP Email Address (NA if not applicable):

Operation Details

Consultant's Name:

Hospital Name:

Date of Surgery:

Proposed Procedure:

Length of Stay:

Personal Details

1) Occupation:

2) Do you follow a special diet?

2a) Please expand:

3) Do you live alone?

4) Do you have any dependents?

If yes, please expand:

5) Who will be looking after you when you go home?

6) Are you hard of hearing?

6a) If yes, please expand:

7) Are you visually impaired?

7a) If yes, please expand:

8) Do you have any concerns about your safety at home?

8a) If yes, please expand:

9) Do you have any communication problems or special learning needs?

9a) If yes, please expand:

10) Is English your first language?

11) Do you intend to undergo any form of continuous travel (e.g. car, train, plane) for more than three hours approximately 4 weeks before or after surgery?

11a) If yes, please expand:

12) What is your weight? (kg):

13) What is your height? (cm):

Previous Anaesthetics

14) Have you ever had problems with a previous anaesthetic?*:

14a) Please provide further details below:

15) Have any of your relatives had problems with anaesthetics?

15a) Please provide further details below:

Allergies

16) Have you ever had a reaction to medicines or other substances (e.g. food/topical agents/latex/metal/other)?

16a) Please state the type of reaction as well as many details as possible below:

Alcohol, Smoking/Vaping and Exercise

17) Do you currently smoke?*:

17a) If yes, how many do you smoke a day?

17b) What date did you start? (NA if not applicable):

18) Have you ever smoked?

18a) If yes, what date did you start? (NA if not applicable):

18b) What date did you quit? (NA if not applicable):

18c) If yes, how many did you smoke a day?

19) Do you vape?

19a) How often do you vape?

20) Do you drink alcohol?

20a) Units per week - A medium glass of wine is 2 units; a single spirit measure is 1 unit and a pint of beer is 2-3 units:

21) Do you take regular exercise?

21a) What type of exercise(s) and how many times per week?

Medication

22) Are you currently taking any form of medications (prescribed, herbal, vitamins, recreational drugs or other)?

22a) Please state what medication, the strength and the frequency below:

23) If taking steroids, do you have a Steroid Card?

Heart Disorder

24) Do you get chest pain or breathless climbing two flights of stairs?

24a) If yes, please provide further details:

25) Do you suffer with angina more than once each month?

25a) If yes, please provide further details:

26) Have you ever had a heart attack?

26a) If yes, please provide further details:

27) Are you currently being treated for an abnormal heart beat?

27a) If yes, please provide further details:

28) Are you currently being treated for heart failure?

28a) If yes, please provide further details:

29) Have you ever been told that you have a heart murmur?

29a) If yes, please provide further details:

30) Are you being treated for high blood pressure?

30a) If yes, please provide further details:

31) Do you have a cardiac pacemaker or internal cardiac defibrillator?

31a) If yes, please provide further details:

32) Do you have any coronary stents?

32a) If yes, please provide further details, (what was the date of insertion?):

Breathing Disorders

33) Do you have asthma, emphysema, chronic bronchitis or any other breathing disorder, including sleep apnoea, cystic fibrosis?

33a) If yes, please provide further details:

34) Do you have asthma attacks more than once each month?

34a) If yes, please provide further details:

Brain and Nerve Disorders

35) Have you been diagnosed as having epilepsy?*:

35a) If yes, Do you have epileptic seizures more than once a month? Please provide further details:

36) Do you have Parkinson's disease, motor neuron disease, MS, cerebral palsy?

36a) If yes, please provide further details:

37) Do you suffer from fainting, falls or blackouts?

37a) If yes, please provide further details:

38) Have you ever had a TIA or stroke?

38a) If yes, please provide further details:

39) Have you a history of CJD or other prion disease in your family? Or have you been notified that you are at an increased risk of CJD or vCJD for public health purposes?*:

39a) If yes, please provide further details:

40) Have you ever had surgery on your brain or spinal cord?

40a) Please provide further details (when, where, etc):

41) Have you ever received growth hormone or gonadotrophin treatment?

41a) If yes, When? Where? Was the hormone derived from human pituitary glands? Please provide further details:

42) Do you suffer with confusion or dementia or have you been diagnosed with Alzheimer's?

42a) If yes, please provide further details:

Stomach and Gut Disorders

43) Do you suffer regularly from indigestion or heartburn?

43a) If yes, please provide further details:

44) Have you ever been treated for a stomach ulcer or hiatus hernia?

44a) If yes, please provide further details:

45) Do you suffer from a bowel condition, e.g. chronic constipation (state laxatives taken) or irritable bowel syndrome or inflammatory bowel disease such as Crohn's disease or ulcerative colitis, or have a stoma?*:

45a) If yes, please provide further details:

Hormone Disorders

46) Do you have diabetes?

46a) If yes, How is it managed? Please provide further details:

47) Do you have thyroid disease?

47a) If yes, please provide further details:

Liver Disease

48) Have you ever had jaundice (yellowness of the skin)?

48a) If yes, please provide further details:

49) Have you ever been diagnosed as having hepatitis?*:

49a) If yes, please provide further details:

Previous Anaesthetics

50) Have you ever had a blood transfusion?

If yes, when?

51) Have you ever been issued with an antibody card?

52) Do you refuse to receive blood or blood products?

52a) If yes, please provide further details:

53) Do you bleed or bruise very easily?

53a) If yes, please provide further details:

54) Have you, or a first-degree relative, ever been diagnosed as having a blood clot in the leg (deep vein thrombosis) or in the lung (pulmonary embolus)?*:

54a) If yes, please provide further details:

55) Have you, or any close relative, been diagnosed with any inherited blood disorder such as sickle cell disease or clotting disorder?

55a) If yes, please provide further details:

56) Have you ever been anaemic?

56a) If yes, please provide further details:

Musculoskeletal Disorders

57) If you sit upright in a chair, do you have difficulties putting your head back far enough to see the ceiling directly above you, while keeping your back straight?

57a) If yes, please provide further details:

58) Have you or a family member ever been diagnosed as having an inherited muscle disease?

58a) If yes, please provide further details:

59) Have you been diagnosed as having arthritis?

59a) If yes, please provide further details:

60) Do you use a mobility aid (e.g. sticks or walking frame)?

60a) If yes, please provide further details:

Urinary and Renal Disorders

61) Have you ever been diagnosed with or treated for acute or chronic kidney disease?

61a) If yes, please provide further details:

62) Are you currently being treated for a urine or bladder infection?

62a) If yes, please provide further details:

63) Do you use a urinary catheter?

63a) If yes, please provide further details:

Skin Disorders

64) Do you currently have any open wounds/ulcers/blisters?*:

64a) If yes, please provide further details:

History of Cancer and/or Transplant

65) Have you ever been diagnosed as having any type of cancer?

65a) If yes, Please provide further details (what type, when and what treatment did you receive?):

66) Have you had an organ/ tissue transplant or stem cell trans-plantation?

66a) If yes, please provide further details:

Previous Operations

67) Have you previously had an operation?

67a) If yes, Please provide further details (any implants or prosthesis inserted, when, where, were there any complications?):*:

Elite Surgical Pre-Operative Questionnaire

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