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What is anaesthesia
Side effects
Your role in your preparation
Fasting
Medications and anaesthesia
Specific procedures
Going Home
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Dental Surgery
Ear Surgery
Gastrointestinal (GI) Endoscopy
Gynaecological Surgery
Hand Surgery
Knee Surgery
Nose Surgery
Tonsillectomy and Adenoidectomy Surgery
Questionnaires
Pre-op questionnaire
Post-op Questionnaire
Paediatric anaesthesia
FAQs
Contact
send a message
Home
About
For Patients
Information
What is anaesthesia
Side effects
Your role in your preparation
Fasting
Medications and anaesthesia
Specific procedures
Going Home
Fees
Surgeons
Hospitals
Types
Dental Surgery
Ear Surgery
Gastrointestinal (GI) Endoscopy
Gynaecological Surgery
Hand Surgery
Knee Surgery
Nose Surgery
Tonsillectomy and Adenoidectomy Surgery
Questionnaires
Pre-op questionnaire
Post-op Questionnaire
Paediatric anaesthesia
FAQs
Contact
Pre-op questionnaire
In order for Dr Hosking to plan the best anaesthetic for you, she needs to know more about you and your health, so please fill out this pre-anaesthetic questionnaire. Your answers are completely secure and confidential.
1
Your Details
2
About Your Procedures and Previous Operations
3
Health History
Patient Name
*
Patient DOB
*
MM slash DD slash YYYY
Your Name
Your relationship to the patient
Your Email
*
Your Telephone Number
*
Name of Patient's Health Fund
*
Height (cm)
*
Weight (kg)
*
Name of operation / procedure you are having
*
Date of Operation
MM slash DD slash YYYY
Who is your Surgeon?
*
Dr Blatt
Dr Cassey
Dr Cornwell
Dr Deshpande
Dr Dunkley
Dr Hunt
Dr Napthali
Dr Pandey
Dr Parkin
Dr Rayner
Other
Which Private Hospital?
*
Hunter Valley
Lingard
Lake Macquarie
Newcastle
Maitland
Warners Bay
Other
Hospital Name
*
Have you previously had any problems with anaesthetic?
*
Yes
No
Please provide details
*
Have any of your blood relatives ever had a problem with anaesthetic?
*
Yes
No
Not that I am aware of
Do you have any allergies?
*
Yes
No
(especially to medications including antibiotics, latex products, foods or iodine)
Please provide details
*
Do you take regular medications?
*
Yes
No
(including all tablets, puffers, patches, sprays, injections, eye drops etc.)
Please provide details
*
Cardiovascular (Heart) History
High Blood Pressure
Chest Pains
Ischaemic Heart Disease (e.g “Heart attack” “angina”)
Coronary artery stents or bypass
Irregular Heart Beat
Heart Valve abnormality
Heart Failure
Have a pacemaker or Defibrillator
Other
Respiratory (Lung) History
Asthma
Bronchitis
Emphysema
Obstructive Sleep apnoea (OSA)
CAL or COPD
Pulmonary embolus
Recent Chest infection
Other
Diabetes
Yes, I'm insulin dependent
Yes, I use a combination of insulin and tablets
Yes I’m non insulin dependent (and take tablets or diet controlled)
No
Gastrointestinal Disease (Gord, Reflux, Gastritis, Oesophagitis, Hiatus Hernia, Stomach or Duodenal Ulcers?
Yes
No
Do you have Kidney Disease?
Yes
No
Do you have Thyroid Disease?
Yes
No
Do you have a Blood Disorder causing blood clots or excessive bleeding? (including a history of deep vein thrombosis (DVT), pulmonary embolism (PE)
Yes
No
Please provide details of any other medical condition not mentioned so far:
Do you have any other specialists looking after your health? Please list name and frequency:
Are you currently taking any medications (including over the counter and herbal medications)?
Yes
No
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Do you take recreational drugs?
Yes
No
Do you regularly exercise?
Yes
No
Have you had a look at the information sheets on this website relevant to your or your child's operation?
Yes
No
Do you have someone to collect you from the hospital and who can help you for the first 24 hours after discharge?
Yes
No
Do you have any other concerns or questions about your anaesthetic?
Yes
No
Would you like to receive a phone call from Dr Hosking prior to your procedure?
Yes
Only if Dr Hosking has specific issues she wishes to discuss
No
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