Pre-Anaesthetic Questionnaire - Dr. Firstname Lastname Backup

Pre-Anaesthetic Questionnaire

Dr. Drew Peacock
Anaesthetist's details
VPAC ID:
Anaesthetist's Full Name and Title
VPAC Email
example@example.com
Opening Message
Addressee
Dear Blud,

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. Drew Peacock

drew.peacock@virtualpac.health
Formatting
Hidden Yes multi-choice

Yes
Hidden No multi-choice

No
Hidden ? multi-choice

?
Impossible
Notifications
Red flag Sx (notifications):
Functional Status x Green Flag:
Red flag Hx (notification):
Red flag Rx (notification):
Phone Call? (notification)
Questions? (notification)
*ALERT*

YesNo

Patient's Details
Name:*

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Today's Date (picker)

DayMonthYear
Age - years
Age (number format)
Age - extra months
Age:
(Auto-filled)
Sex:*
Are you pregnant or breastfeeding?
O&G Alert:

PregnantBreastfeeding
Height (cm)
Weight (kg)
BMI (calc)
BMI (number format)
Height & Weight
Phone Number:*
Mobile Phone Number
Email:*
example@example.com
Are you filling out this form yourself?
Filling out own form?

YesNo

Emergency Contact

e.g. parent, child, spouse
Contact's Name:*

Contact's First NameContact's Last Name
Relationship to patient:*
e.g. parent, daughter/son, friend
Contact's Phone Number:*
Mobile Phone Number

Doctors' Details
Do you have a regular General Practitioner?
General Practitioner:

No
General Practitioner:
Do you see any specialists?
Specialists:

No
Specialists:
May I request your medical information from other healthcare providers?*
Permission to request medical info:

YesNo

Operation Details
Are you having any of the following day procedures under sedation?*

Gastroscopy or colonoscopyNerve block or ablationSkin lump removal or biopsyFinger or toe surgeryEye surgery*NONE OF THE ABOVE*
Green Flag Operation:
What operation are you having?*
Operation:
Who is your surgeon/proceduralist?*
Proceduralist:
When is your operation?

DayMonthYear
Date
Time (if known)AM/PM Option
Date:

DayMonthYear
Date
Where is your operation?*
Name of hospital
Location:
Why are you having this operation?*
Indication:
Start

DayMonthYear
Start Date/Time for Calendar
Hour MinutesAM/PM Option
Finish

DayMonthYear
End Date/Time for Calendar
Hour MinutesAM/PM Option

Past Medical History

Other
Have you had any medical problem not listed above?
Please provide details:
Other Medical Hx:

No
Other Medical Hx:

Attachments
Are there any documents you would like to share with your anaesthetist?
Attachments

No
File 1

Cancelof
File 2

Cancelof
File 3

Cancelof
File 4

Cancelof
File 5

Cancelof

Final questions
Would you like your anaesthetist to call you prior to the procedure?*
Request for pre-op phone call:

YesNoDon't mind
Do you have any specific questions, concerns or requests?*
Please provide details:
Special requests:

No
Special requests:
*DISCLAIMER*

Regarding use of this questionnaire
Should be Empty: