FacebookThis field is for validation purposes and should be left unchanged.It is important that you speak to your doctor about when you should stop eating and drinking before your anaestheticThe Anaesthetist will also need to know the following:Any recent coughs, colds or feversAny previous anaesthetics or family problems with anaesthesiaAbnormal reactions or allergies to drugsAny history of Obstructive Sleep Apnoea, asthma, bronchitis, heart problems or other medical problemsAny medications you may be takingThe 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 QiuWhat is your age? **What is your height? **What is your weight? **Are you of Aboriginal or Torres Strait Islander origin?* Yes NoDo you have a responsible adult to accompany you home?* Yes NoSecondary 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 NoDetails*Have you had problems with your lungs, asthma or obstructive sleep apnea?* Yes NoDetails*Do you use a CPAP machine?* Yes NoDetails*Have you had any problems with your heart or blood pressure?* Yes NoDetails*Do you have a pacemaker or artificial heart valve?* Yes NoDo you have diabetes?* Yes NoHave you had any problems with your liver?* Yes NoDo you have a kidney disease?* Yes NoHave you had any other serious illnesses?* Yes NoDo you have a history of any bleeding tendencies?* Yes NoHave you had an anaesthetic?* Yes NoWhat was the procedure?*Were there any complications with the surgery or anaesthetic?* Yes NoDetails*Are you taking any medicines or tablets?* Yes NoIf yes, please spedity*Do you drink alcohol or use recreational drugs?* Yes NoDetails*Do you or have you recenty had any type of infection?* Yes NoHave you recently travelled overseas?* Yes NoWhere 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 NoIf yes, please select:* Pradaxa Clopidogrel Warfarin Anti-inflammatory drugsLast dose taken:*Do you smoke?* Yes NoIf yes, how many per day? | When did you quit?Do you have any physical disabilities?* Yes NoCould you be pregnant?* Yes NoLast menstrual period*Have you had two or more accidental falls in the past 12 months?* Yes NoDo you have an Advanced Care Plan and other treatment-limiting orders?* Yes NoDetails*Do you have a hearing aid, prosthesis, contact lenses or body piercing?* Yes NoDo you have any loose teeth, caps or crowns?* Yes NoHave you had recent pathology tests?* Yes NoLaboratory name*Have you had recent X-rays or an ECG?* Yes NoFacility 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 NoCAPTCHA
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