• Pre-Anaesthetic Questionnaire

    Pre-Anaesthetic Questionnaire

    Dr. Hugh Jass

  • Anaesthetist's details

  • Opening Message

  • Dear Patient,

     

    Thank you for taking the time to complete this form. It helps me to:

    • Tailor your anaesthetic, thereby improving safety and comfort
    • Request information ahead of time, so as to avoid delay or cancellation
    • Spend more of our consultation discussing matters important to you

     

    If you are unable to complete the form, please let me know.

     

    All information gathered will be stored in HIPAA-compliant servers, and will not be released without your permission.

     

    Sincerely,

    Dr. Hugh Jass

    hugh.jass@virtualpac.health

  • Formatting

  • Notifications

  • *ALERT*

  • Patient's Details

  • Date of Birth:
     - -
  • Today's Date (picker)
     - -
  • O&G Alert:
  • Format: 0400000000.
  • Filling out own form?

  • Emergency Contact

    e.g. parent, child, spouse
  • Format: 0000000000.

  • Doctors' Details

  • Permission to request medical info:

  • Operation Details

  • Are you having any of the following day procedures under sedation?
  • When is your operation?
     - -
  • Date:
     - -
  • Start
     - -
  • Finish
     - -

  • Recent Health

  • What is your present level of physical activity?
  • Exercise tolerance:
  • Have you had any of the following symptoms in the past few months?
  • CVS Sx:
  • Have you had any respiratory illnesses in the past few weeks?
  • Recent URTI/LRTI:
  • Do you experience reflux / heartburn / indigestion?
  • Dyspepsia Sx:
  • Do you experience regurgitation / waterbrash?
  • Regurgitation Sx:

  • Recent Investigations

  • Have you had any of the following tests in the past year?
  • Cardio-respiratory Ix:

  • Past Surgical & Anaesthetic History

  • What types of anaesthetic have you had before? (select all that apply)
  • Anaesthetic Hx:
  • Have you ever had problems with an anaesthetic?
  • Anaesthetic Problems:
  • Motion sickness:
  • Has any of your blood relatives had a reaction to an anaesthetic?
  • Anaesthetic FHx:
  • Regarding your teeth, select all that apply:
  • Dental Hx:

  • Medications & Allergies

  • Do you take any of the following types of medications?
  • Red flag medications:

  • *Please list all your medications below*

  • *Please list those instructions below*

  • *Please list your allergies below*

  • Substance use

  • Do you smoke or vape?
  • Smoking/Vaping Hx:
  • Do you consume alcohol?
  • Alcohol Hx:
  • Have you used any recreational drugs in the past few weeks?
  • Recreational Drug Use:

  • Past Medical History

    Pregnancy
  • Have you had any medical issues during this pregnancy?
  • Pregnancy Cx:

  • Past Medical History

    Cardiorespiratory status
  • Have you had any heart issues?
  • Cardiac Hx:
  • Have you had any heart procedures?
  • Cardiac Rx:
  • Have you had any lung issues?
  • Resp Hx:

  • Past Medical History

    Metabolic status & Malignancy
  • Have you had any of the following metabolic issues?
  • Metabolic Hx:
  • CPAP/APAP:
  • Do you have any symptoms of sleep apnoea?
  • OSA Sx:
  • Cancer Hx:
  • Type(s):
  • Which treatments have you undergone?
  • Treatment:
  • Active Rx:
  • Have you experienced any treatment side effects?
  • Side effects:

  • Past Medical History

    Digestion, internal organs, blood
  • Have you had any gastrointestinal issues?
  • GIT Hx:
  • Have you had issues with any of the following internal organs?
  • Solid organs:
  • Have you had any blood issues?
  • Haem Hx:

  • Past Medical History

    Neurological and mental health status
  • Have you had any neurological issues?
  • Neuro Hx:
  • Have you had any mental health issues?
  • Psych Hx:

  • Past Medical History

    Skin, bone, joint, connective tissues
  • Have you had any skin problems?
  • Derm Hx:
  • Have you had any joint problems?
  • MSK Hx:
  • Do you have any neck problems?
  • C-spine Hx:
  • Have you had any autoimmune, inflammatory or connective tissue disease?
  • Autoimmune Hx:

  • Past Medical History

    Other

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  • Final questions

  • Request for pre-op phone call:

  • *DISCLAIMER*

    Regarding use of this questionnaire

  • Should be Empty: