Pre-op Questionnaire

Your Health Information

No-one likes filling out forms, but this information is extremely useful for your Anaesthetist, to look after you. Thank you.

First name * Last name * Date of birth *

Gender * Mobile number * No spaces. Digits only.

Height (m) Weight (kg)

Do you suffer from reflux / heartburn?

Medications

Type to search. Tap a suggestion to add it. You can also type a custom medication and press Enter. Allergies (comma or new line) If none, leave blank.

Family history of anaesthetic problems If none, leave blank. Include relationship (e.g. "father — malignant hyperthermia").

Notes (optional)

I consent to my health information being collected and used for pre-operative assessment by my anaesthetist. I understand this data is stored securely and handled in accordance with the Privacy Policy and the Australian Privacy Act 1988.

Your Health Information

Breathing / lungs

Heart / circulation

Other medical history

Teeth / dental

Previous anaesthetic issues

Previous surgery