Royal Perth Hospital - Preadmission health assessment questionnaire

Instructions

To Help us with the assessment process, we ask you take 15 minutes of your time to fill in this questionnaire. It is important you give us as much information as possible because this will help us to establish your medical fitness for anaesthetic so surgery can proceed safely. This could decrease your waiting time for surgery.

What happens next ?

The Central Wait List team will contact you after triage to book you into an appointment in the PAAS clinic, organise a telephone appointment with the screening nurse or give you a surgical date straight away.

All information provided here is de-identified and will be treated in confidence. You will receive a letter from the hospital with the details of your surgery date or a pre-admission appointment (if necessary) in due course.

Do you have a Carer / nominated person to be involved in your care? Yes No

Carer / nominated person name Relationship to patient Contact details

Do you have a Guardian / Public Advocate? Yes No

Name Relationship Contact details

Do you require an interpreter? Yes No

Which language?

Do you have difficulty hearing? Yes No

Do you use hearing aids? Yes No Can you hear well when using the telephone? Yes No

Do you have an Advance Health Directive? Yes No

If Yes, please bring a copy with you on admission to hospital.

Please complete the following questions and give as much detail as possible.

If completing this assessment at home, try and complete as much as possible.

You can email RPH.SV4ScreeningNurse@health.wa.gov.au for assistance.

Section 1: Physical Activity and Fitness

Your Physical Activity and Fitness I climb 2 flights of stairs easily without resting I climb 1 flight of stairs easily without resting I walk 1-2 blocks (500m - 1km) on ground level I walk about my house and garden I am unable to walk or I am wheelchair bound

Section 2: General Information

What do you weigh (kg's)? What is your height (cm's)? Have you lost weight recently, unintentionally? Yes No Do you smoke? Yes No

How many per day?

If you did smoke and have now stopped, when did you give up?

Do you drink alcohol? Yes No

How many drinks per day or week on average?

Do you take any recreational (party) drugs (e.g. amphetamines, marijuana, ice, cocaine)? Yes No

What? How much? How often?

Could you be pregnant? Yes No Are you currently breastfeeding? Yes No Have you had any serious infectious diseases (e.g. Tuberculosis, HIV)? Yes No

Please provide details

Is there a family history of significant disease (e.g. thalassaemia, malignant hyperpyrexia, haemophilia, Von Willebrand disease)? Yes No

Please provide details

Have you been in a hospital outside of WA in the last 12 months? Yes No

Please provide details

Would you consent to having blood products? Yes No

Section 3: Medication

If you have a regular community pharmacy, please provide name

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)

Please bring them with you to Pre Anaesthetic Assessment Clinic

Please enter each medication on a newline in the format (e.g. Name of Medication, Dose, How often) Are you Allergic to anything? Yes No

Please provide details

Blood Thinners: Do you take any blood thinning (e.g. Warfarin (Coumadin/Marevan), Aspririn, Clopidogrel (Iscover/Plavix/Prasugrel), Rivaroxaban, Apixabin, Dabiagatran or any other blood thinning drugs / injections? Yes No

Please provide details

Section 4: Heart related conditions

Do you have any known heart conditions (e.g. angina, heart attacks, palpitations, irregular heart beat)? Yes No

Section 5: Lung / Breathing conditions

Do you have any lung or chest conditions (e.g. asthma, chronic bronchitis, emphysema, sleep apnoea)? Yes No

Section 6: Sleep Apnoea

Do you have Sleep Apnoea? Yes No

Have you had sleep studies carried out? Yes No

Where? When?

Have you used a CPAP machine? Yes No

Could you have sleep apnoea? The following questions assess your risk.

Do you snore loudly? (enough to disturb others) Yes No Do you often feel tired or sleepy during the daytime? (such as falling asleep talking to someone, or driving) Yes No Has anyone ever observed you stop breathing or choke/gasp in your sleep? Yes No Is your neck circumference greater than 40cm? Yes No

Section 7: Endocrine conditions

Have you ever had any of the following?

Thyroid problems Yes No

Please provide details

Diabetes Yes No

Please select how it is controlled Diet Tablets Insulin Other

Please provide details

Other Endocrine conditions: Pituitary, Addisons, Pheochrmocytoma Yes No

Section 8: Liver / Kidney / Bowel conditions or concerns with excessive Bruising / Bleeding / Blood Clots or Anaemia

Do you have any Liver, Kidney or Bowel health problems or concerns with excessive Bruising, Bleeding, Blood clots or Anaemia ? Yes No

Section 9: Neurological

Have you ever had any of the following?

Stroke (CVA) including Mini Stroke also called Transient Ischaemic Attack (TIA) Yes No

Was it in the last 6 months? Yes No What hospital did you attend?

Muscle disease, progressive weakness or Creutzfeldt-Jakob disease Yes No

Please provide details

Epilepsy, blackouts or fits Yes No

How often? Daily Weekly Monthly Other

Please provide details

Do you have any trouble with your memory? Yes No

Please provide details

Have you had any trips or falls in the last twelve months? Yes No

Please provide details

Have you experienced any dizziness? Yes No

Please provide details

Do you have Parkinson's disease? Yes No

Please provide details

Do you have any existing Chronic (long term) pain? Yes No

Where is the pain located? What usually helps relieve the pain?

Do you have any mental health concerns (e.g. Anxiety, Depression, Mental Illness or Emotional distress)? Yes No

Please provide details

Section 10: Musculoskeletal

Have you ever had any of the following ?

Do you have any joint / arthritis problems ? Yes No

Please provide details

Neck / back spinal problems ? Yes No

Please provide details

Section 11: Anaesthetic and Surgical History

Please list any operations you have had below

Please enter each operation on a newline in the format (e.g. Operation, When, Location/Hospital) Have you or any member of your family ever had any problems with an anaesthetic? Yes No

Please provide details

Do you have problems with Jaw movement? Yes No

Please provide details

Do you have a Gastric Reflux? Yes No

Please provide details

Please detail any other medical information not already mentioned

Section 12: Relevant other details

Do you normally need assistance or require an aid to walk (e.g. stick, frame or wheelchair)? Yes No

Please provide details

Do you have a disability? Yes No

Please provide details

Do you receive community services? Yes No

Please provide details

Do you currently have any problems with showering / toileting / dressing? Yes No

Please provide details

Are you the main carer for another person? Yes No

Please provide details

Please include any further relevant information below

Patient Declaration

Royal Perth Bentley Group is committed to safeguarding the privacy of patient information. We take all reasonable steps to safeguard your information which is held in either paper or electronic files by storing them securely.

It may be necessary for us to obtain copies of reports such as x-ray’s, pathology results and correspondence from other medical practitioners, healthcare professionals or your general practitioner regarding your medical treatment.

If you do not wish for us to collect and release information about you, you need to tell us and we will discuss with you the impact this may have for your health care. Please call RPH 6477 5139 / BHS 9416 3824.

Royal Perth Bentley Group conducts a wide variety of research projects that aim to guide best practice in surgical patients. Individuals that are eligible for specific projects will be routinely approached by research staff to discuss whether they wish to participate.

Useful websites for more information:
HealthyWA - Going to hospital
WA Health YouTube

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Pre-Admission Health Assessment Questionnaire

Instructions

What happens next ?

Please complete the following questions and give as much detail as possible.

Section 1: Physical Activity and Fitness

Section 2: General Information

Section 3: Medication

Section 4: Heart related conditions

Do you have, or have you had, any of the following?

Section 5: Lung / Breathing conditions

Do you have or have you had any of the following?

Section 6: Sleep Apnoea

Could you have sleep apnoea? The following questions assess your risk.

Section 7: Endocrine conditions

Have you ever had any of the following?

Section 8: Liver / Kidney / Bowel conditions or concerns with excessive Bruising / Bleeding / Blood Clots or Anaemia

Section 9: Neurological

Have you ever had any of the following?

Section 10: Musculoskeletal

Have you ever had any of the following ?

Section 11: Anaesthetic and Surgical History

Please list any operations you have had below

Section 12: Relevant other details

Patient Declaration