Sir Charles Gairdner Hospital - Pre-Anaesthetic Health Assessment

What is your primary spoken language? English Other

Please specify your primary spoken language

Do you require an interpreter? No Yes

What is your weight (kg)? Uncertain

What is your height (cm)? Uncertain

Have you been hospitalised outside WA within the last 12 months? No Yes

Admission and Discharge Needs

Will you have access to transport home and overnight care? No Yes

Please describe

Do you live alone? No Yes

Please describe

Do you live in a nursing home or residential care? No Yes

Please describe

If you are a primary carer for someone, do you need help to organise their care while you recover? No Yes

Please describe

Do you need help with self-care? e.g. bathing, dressing No Yes

Please describe

Do you receive support services? e.g. home help, NDIS, ACAT, Silver Chain etc. No Yes

Please describe

Do you use a mobility aid? e.g. zimmer frame, walking stick, wheelchair etc. No Yes

Please describe

Medication Alerts

Do you take ‘blood thinners’? e.g. warfarin, clopidogrel, apixaban No Yes

Please describe

Do you use very strong pain medications for acute or chronic pain? e.g. methadone, fentanyl, oxycodone, transdermal patch No Yes

Please describe

Have you had radiotherapy? No Yes

Please describe

Have you had chemotherapy? No Yes

Date of last dose:

Have you taken steroids in the last year? No Yes

Please describe

Do you drink alcohol? No Yes

How much daily?

Are you a smoker? No Yes

How much daily?

Are you on a community opioid program? e.g. methadone, Suboxone, Buvidal No Yes

Please describe

Have you taken recreational drugs in the past year? No Yes

Which drug? How often?

Current Medications

Do you take any medications - Including natural, herbal and recreational drugs, inhalers and insulin? No Yes

Do you take more than 5 medications? No Yes Please list ALL medication you are currently taking including puffers, patches, injections, contraceptive pill, creams, eye/ear medications, over the counter non prescribed medication (e.g. herbal/naturopathic/vitamins and complementary)

Name of Medication	How much? (Dose)	How often each day? (Frequency)

Allergies

Do you have allergies to medications? No Yes

Please describe

Do you have any other allergies? (latex / tape / dietary) No Yes

Please describe

Surgical and Anaesthetic Alerts

Do you have any medical implants? e.g. pacemaker / defibrillator / valves / stents No Yes

Please describe

Have you ever been told you have a ‘difficult airway’ or there was difficulty with placement of a breathing tube while you were anaesthetised? No Yes

Please describe

Would you object to having a blood transfusion if needed? No Yes

Please describe

Have you or your immediate family had a serious anaesthetic reaction? e.g. malignant hyperthermia No Yes

Please describe

Medical History

Do you have a history of:

Heart attack / chest pain / angina / heart disease? No Yes

Date Please describe

Shortness of breath after ONE flight of stairs? No Yes

Please describe

Irregular heart beat? Heart murmur? No Yes

Please describe

Stroke, TIA’s or blackouts? No Yes

Ongoing impairment? No Yes

High blood pressure? No Yes

Please describe

Blood clots / bleeding disorders / recurrent blood transfusions? No Yes

Please describe

Type 1 Diabetes? No Yes

Do you use an Insulin Pump? No Yes

Type 2 Diabetes? No Yes

Do you take Insulin? No Yes

Sleep apnoea / heavy snoring? No Yes

Treated with CPAP? No Yes

Lung disease? e.g. chronic bronchitis, emphysema or asthma? No Yes

Any recent hospitalisation? No Yes

Epilepsy or fits? No Yes

Please describe

Infections? e.g. TB, Hep B or C, MRSA, VRE, HIV? No Yes

Please describe

Mental health vulnerabilities? e.g. depression, anxiety No Yes

Please describe

Kidney disease or bladder problems? No Yes

Are you on dialysis? No Yes

Liver disease? No Yes

Please describe

Muscle disease or progressive weakness? No Yes

Please describe

Neck / back / joint problems? No Yes

Please describe

Short term memory loss or dementia? No Yes

Please describe

Reflux / indigestion / hiatus hernia? No Yes

Please describe

Cancer of any type? No Yes

Please describe

Could you be pregnant? No Yes

Please describe

Are you breastfeeding? No Yes

Please describe

Do you have any other health conditions not mentioned? No Yes

Please describe

Surgical History

Please list past operations and year of surgery

Have you had any previous surgeries? No Yes

Please list past operations and year of surgery

Operation	Year of surgery

Acknowledgement

I have given completed and accurate answers to this questionnaire to the best of my knowledge.

Patient Name Have you had help to complete this form? No Yes

Pre-Anaesthetic Health Assessment

Instructions for the patient completing this form

Please complete all the questions and provide further details in the boxes as required

This form is uniquely linked to your patient number and can only be submitted once.

Admission and Discharge Needs

Medication Alerts

Current Medications

Allergies

Surgical and Anaesthetic Alerts

Medical History

Do you have a history of:

Surgical History

Please list past operations and year of surgery

Acknowledgement

I have given completed and accurate answers to this questionnaire to the best of my knowledge.