PRE-OPERATIVE ASSESSMENT HEALTH QUESTIONNAIRE. Welcome to the pre operative assessment clinic.

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1 PRE-OPERATIVE ASSESSMENT HEALTH QUESTIONNAIRE Welcome to the pre operative assessment clinic. Here you will be seen by a pre-op nurse assessor who may ask questions about your general health. You will also have an opportunity to ask questions regarding your admission for your surgery, reducing any anxieties you may have. To help us with the assessment process we ask you to take 5 10 minutes of your time to fill in this health questionnaire. It is important you give as much detail as possible as it will help us to establish your medical fitness for anaesthetic so that the procedure can proceed safely. This questionnaire is based on a scoring system and will help us to place you in the appropriate clinic. If you are unsure about any of the question s or having difficulty completing the health questionnaire please ask one of the Nurse s who will be happy to help. All information given will be treated in confidence. Date Pre-operative Nurse

2 Initial pre-operative assessment screening proforma FOR STAFF USE ONLY Consultant :... DEMOGRAPHICS General practitioner :. Planned procedure : FOR PATIENT USE Contact numbers: Home: Mobile: Work: Occupation: Dates not available for surgery (e.g. holiday, family event): Section 1 Have you ever had or do you have any of the following? YES NO 1. High blood pressure (hypertension) If yes is it controlled? 2. Chest Pain / Angina If yes is it controlled? 3. Heart attack Within the last 6months 4. Palpitations / Irregular heart beat If yes please describe? 5. Heart murmur / Rheumatic fever Pace-maker / Internal cardiac device Any other heart disease? If yes, please describe Are you currently under the care of a cardiologist? If yes please give details 2

3 Section 2 Have you ever had or do you have any of the following? YES NO 8. Asthma If yes is it controlled? Good 1 Fair 3 Poor 5 9. Emphysema or chronic bronchitis If yes is it controlled? Good 1 Fair 3 Poor Have you had TB (Tuberculosis)? Have you ever been told that you have obstructive sleep apnoea? Any other chest disease? If yes, please describe Section 3 Have you ever had any of the following? YES NO 13. Thyroid problems (such as over or under-active thyroid) Diabetes If yes is it controlled Section 4 Have you ever had any of the following? YES NO 15. Kidney, bladder or urinary problems Are you receiving dialysis? Have you ever had a transplant? Liver disease yellowness / jaundice Excessive bleeding / bruising Blood clot Embolism Deep vein thrombosis - clotting disorder Anaemia If yes are you taking iron suppliments? 1 0 Section 5 Have you ever had any of the following? YES NO 20. Stroke (CVA) In the last 6 months Mini stroke (TIA) In the last 6 months Muscle disease or progressive weakness Epilepsy or fits If yes please describe - Daily 5 Weekly 3 Monthly 2 Less 1 3

4 Section 6 Anaesthetic Have you ever had any of the following? YES NO 23. Have you ever had an anaesthetic for an operation in the past? If yes, please describe what operation and when? 24. Have you or a family member had problems with a previous anaesthetic? 5 0 Section 7 General YES NO 25. Do you have any problems with restricted neck or jaw movement? Do you have any other joint or arthritis problems? 27. Have you received Growth Hormone injections before 1985, or undergone brain/spinal surgery before 1992, or received a corneal implant? 28. Do you suffer from a depression, anxiety state, mental illness? below: 29. Do you ever get any heartburn (acid running into the back of your mouth) when bending forward or lying flat? 30. Have you had an infection caused by MRSA (Methicillin resistant staphylococcus aureus)? 31. Do you see your GP regularly for any other reasons? If yes, why? 4

5 YES NO 32. Have you smoked within the last 5 years? 33. Do you smoke now? If yes, how much a day? 34. Is there any possibility that you may be pregnant? 35. Do you drink more than 1 1/2 pints of beer or 3 shorts or 1/2 bottle of wine per day most days? Do you take any regular medicines? If yes, please list name of the medicine, the dosage and number of times a day you take the medicine. 5

6 Please indicate any of the following medications that you may be taking? Contraceptive pill HRT Patches Anticoagulant tablets Steroid tablets (prednisolone) Herbal medication Over the counter medication Eye drops Inhalers Recreational drugs MAOI tablets (You will carry a card if you do) 6

7 37. Do you have allergies (such as drugs, plasters, latex, antiseptics, food stuffs e.g. bananas, fish, nuts, eggs and pollen). allergy & also describe the reaction: YES NO Any drugs that disagree with you? Please state. 38. any other hospital admissions in the last 5 years? 39. Is there anything else you think the surgeon, anaesthetist or nurse should know? If yes, describe: 7

8 40. Is there any reason you will not be able to manage at home after your operation? If yes, describe: YES NO 41. Will you be taken home by a responsible adult (aged 18+) after your operation? 42. Will you have the responsible adult at home for 24 hours to look after you? Name.. Signature.. Date 8

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