It is important that you speak to your doctor about when you should stop eating and drinking before your anaesthetic The Anaesthetist will also need to know the following: Any recent coughs, colds or fevers Any previous anaesthetics or family problems with anaesthesia Abnormal reactions or allergies to drugs Any history of Obstructive Sleep Apnoea, asthma, bronchitis, heart problems or other medical problems Any medications you may be taking The form below must be completed and returned to the Surgeon at least 48 hours prior to your surgery in order to proceed with your operation.Patient Name*Date of Surgery ** MM slash DD slash YYYY Your surgeon* Mr Verco Mr Woods Mr Savage Dr Qiu What is your age? **What is your height? **What is your weight? **Do you have a responsible adult to accompany you home?* Yes No Secondary Contact Details (Next of Kin / Emergency / Family)NOK First Name*NOK Last Name*NOK Relationship*NOK Phone Number*Do you have any allergies or alerts?* Yes No Details*Have you had problems with your lungs, asthma or obstructive sleep apnea?* Yes No Details*Do you use a CPAP machine?* Yes No Details*Have you had any problems with your heart or blood pressure?* Yes No Details*Do you have a pacemaker or artificial heart valve?* Yes No Do you have diabetes?* Yes No Have you had any problems with your liver?* Yes No Do you have a kidney disease?* Yes No Have you had any other serious illnesses?* Yes No Do you have a history of any bleeding tendencies?* Yes No Have you had an anaesthetic?* Yes No What was the procedure?*Were there any complications with the surgery or anaesthetic?* Yes No Details*Are you taking any medicines or tablets?* Yes No If yes, please spedity*Do you drink alcohol or use recreational drugs?* Yes No Details*Do you or have you recenty had any type of infection?* Yes No Have you recently travelled overseas?* Yes No Where did you travel?*Have you been exposed to any infectious diseases? (i.e. COVID 19, lepatus, HIV, Mad Cow, SARS)* Yes No (i.e. COVID 19, Hepatitis, HIV, Mad Cow, SARS)*Have you recently taken Aspirin or other blood thinning medication?* Yes No If yes, please select:* Pradaxa Clopidogrel Warfarin Anti-inflammatory drugs Last dose taken:*Do you smoke?* Yes No If yes, how many per day? | When did you quit?Do you have any physical disabilities?* Yes No Could you be pregnant?* Yes No Last menstrual period*Have you had two or more accidental falls in the past 12 months?* Yes No Do you have an Advanced Care Plan and other treatment-limiting orders?* Yes No Details*Do you have a hearing aid, prosthesis, contact lenses or body piercing?* Yes No Do you have any loose teeth, caps or crowns?* Yes No Have you had recent pathology tests?* Yes No Laboratory name*Have you had recent X-rays or an ECG?* Yes No Facility name*Do you have a responsible person to stay with you at home, at least overnight, following your discharge from the surgical procedure and sedation?* Yes No CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
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