TBOFC Preoperative

PREOPERATIVE ASSESSMENT – ANAESTHESIA QUESTIONNAIRE

Dr. Stefanie Gubbay (Specialist Anaesthetist)

Enquiries: 0402 745 028 – Collective Anaesthetic Group

Name *

Date of Birth *

Postal Address *

Suburb *

State *

Postcode *

Home Phone

Mobile

Work Phone

Please enter at least one phone number

Email *

GP's Name and Phone No *

Operation *

Operation Date *

Surgeon *

Hospital *

Medicare No *

Private Health Fund (Hospital Cover) *

HF No. *

List all medications you are currently taking, including inhalers and over the counter medications. State dose and times.

List previous operations you have had including approximate dates.

Have you, or any relative of yours ever had a complication to do with an anaesthetic? If yes, give details.

Do you have any allergies, incl. latex, rubber or foods? If yes, give details & describe the nature of the reaction (e.g. rash, anaphylaxis).

Do you smoke? *

YesNoUsed to

How many per day & for how long?

When did you stop?

Do you use recreational drugs? *

YesNo

Which drugs and how often?

Do you drink alcohol? *

YesNo

How often & how much (daily / weekly / monthly)

Do you have any loose or cracked teeth? If yes, which ones?

Do you have any other health problems that you feel your Anaesthetist should know about?

Your weight (kg) *

Your Height (cm) *

FASTING and MEDICATIONS

For adults: limited solid food (e.g. a light breakfast) may be taken up to six hours prior to anaesthesia and clear fluids may be taken up to two hours prior to anaesthesia. Clear fluids are regarded as water, pulp free fruit juice, clear cordial, black tea and coffee. It excludes particulate or milk-based drinks.

For Children over six months: breast milk or formula and limited solid food (e.g. a light breakfast) may be given up to six hours prior and clear fluids up to two hours prior to anaesthesia.

Prescribed Medications: may be taken with a sip of water less than two hours prior to anaesthesia unless otherwise directed (for example Diabetes medication and Blood thinning medication)

CONSENT TO ANAESTHESIA

Please tick below boxes as appropriate before signing:

The information I have supplied in this questionnaire is accurate to the best of my knowledge.

I have read & understood the PDF brochure “About Your Anaesthetic” by QLD Health. I will take the opportunity to ask Dr Gubbay any questions I may have prior to my anaesthetic. I am aware that Dr Gubbay is happy to be contacted to discuss any questions.

Consent to obtain and share medical information.
I consent for Dr Gubbay and associated staff to obtain and share any health related information with and from any of my past, present and future doctors, hospitals or other health professionals in as far as required to provide care, and as permitted under privacy legislation.

Consent to communicate with Health Funds.
I consent for Dr Gubbay and any associated staff to communicate with my Health Fund (Private Health Fund, Medicare, DVA, Workcover etc.) as required and as permitted by law. This includes billing and audit purposes and may also include information about medical conditions and procedures.

Consent to communicate electronically.
I consent for Dr Gubbay and any associated staff to communicate electronically with me or other involved third parties (i.e. email, fax, skype etc.) I accept the small risk of information being illegally intercepted by unauthorized third parties.

Agreement.
I agree not to drive a car, ride a motorcycle or bicycle or operate hazardous machinery within 24 hours of my anaesthetic. Within this period, I also agree not to drink alcohol or make important decisions (i.e. appear in court or sign a contract). I agree to have a responsible adult accompany me home and stay with me for 24 hours following my anaesthetic.

Fees and Charges.
Some costs are not covered by health funds and may be passed on to patients as “out of pocket expenses”. You will be sent an “Informed Financial Consent” (IFC) should this apply to your procedure/anaesthetic.

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