Fillable HEALTH ASSESSMENT (National Asthma Council Australia)

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HEALTH ASSESSMENT (National Asthma Council Australia)

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The HEALTH ASSESSMENT (National Asthma Council Australia) form is 2 pages long and contains:

  • 1 signature
  • 151 check-boxes
  • 88 other fields

Country of origin: AUSTRALIA
File type: PDF

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08/16
OTF- 03
1
Procedure:
Patient Medical & Surgical History
Physical
DOB: _______________________ Age: ______________________
Height: ___________________cm Weight: _________________kgs
Cardiac
High Blood Pressure Yes No
High Cholesterol Yes No
Anemia Yes No
Chest Pain / Angina Yes No
Heart Attach / AMI Yes No If Yes Date: ____________________________
Blood Clot (DVT) Lungs / Legs Yes No
Rheumatic Fever Yes No
Do you smoke Yes No If Yes: How many ________________________
Endocrine
Diabetes Yes No
If Yes: Type 1 Type 2 IDDM Insulin Dependent NIDDM Diet / Insulin / Tablet
Respiratory
Chronic Obstructive Airway Disease Yes No
Asthma Yes No
Bronchitis Yes No
Hay Fever Yes No
Pneumonia Yes No
Shortness of Breath Yes No
Cough / Cold / Sore Throat Yes No
Vascular
Peripheral Vascular Disease Yes No
Varicose Veins Yes No
Poor Circulation to Hands / Feet Yes No
Pressure Ulcer Sore / Venus Ulcer Yes No If Yes: Location _____________________________
GI
Indigestion / Reflux Yes No
Bowel Disease Yes No
Incontinence Issues Yes No If Yes: Bowel Bladder
Kidney Disease Yes No
Liver Disease Yes No
Neurological
Stroke Yes No
TIA (Trans Ischemic Attack) Yes No
Epilepsy / Seizure Yes No
Sleep Disorders Yes No
Fainting / Dizziness Yes No
Falls History Yes No If Yes Please State ___________________________
Neck or Back Issues Yes No If Yes Please State ___________________________
Mental Health / Stress Conditions Yes No If Yes Please State ___________________________
Additional support during admission Yes No If Yes Please State ___________________________
Previous
Surgery
Anaesthetic Issues
(include family issues)
Yes No If Yes Please State ___________________________
_________________________________________________________________________________________
Joint Replacement Yes No If Yes: Location _____________________________
Heart / Valve Replacement Yes No If Yes: Year _________________________________
Angioplasty / Cardiac Stent Yes No
Cardiac Pacemaker / Defibrillation Yes No
Renal Stent Yes No
Lens Implant Yes No
HEALTH
ASSESSMENT
Email: theatrereception@canossa.org.au
Ph: 07 33755107 Fax: 07 33754902
HOSPITAL ADMINISTRATION SECTION ONLY
FAMILY NAME: UR:
FIRST NAMES:
DATE OF BIRTH: GENDER:
AFFIX PATIENT LABEL HERE
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08/16
OTF- 03
2
Skin Cancer Yes No If Yes Type / Location _______________________
_________________________________________________________________________________________
Other Implants Yes No If Yes Please State ___________________________
List other previous surgery details: _____________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Allergies &
Sensitivity
Tapes / Lotions Yes No
Latex or Rubber Yes No
Food (Kiwi Fruit, Banana etc) Yes No If Yes Please Describe ________________________
_________________________________________________________________________________________
Medications Yes No If Yes Please List _____________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Other Allergies Yes No If Yes Please List _____________________________
_________________________________________________________________________________________
Other
Pregnant Yes No N/A
Eczema/Dermatitis/Psoriasis Yes No If Yes Please State____________________________
Arthritis Yes No
Mobility Aids Yes No
Vision Impaired Yes No
Hearing Impaired / Aids Yes No
Dental Appliance
(cap / crowns / bridge) Yes No If Yes Please State ____________________________
Fragile Skin Yes No
Bruise / Bleed Easily Yes No If Yes Please State ____________________________
Blood Transfusion Yes No
Blood Transfusion Reaction Yes No If Yes Please Describe_________________________
_________________________________________________________________________________________
Alcohol Intake Yes No If Yes Amount ________ Frequency_____________
Recreational Drugs Yes No If Yes Type___________ Date last intake _________
Current
Medication
Blood Thinners Yes No If Yes Please Describe _________________________
Blood Thinners Ceased Yes No If Yes Date___________________________________
Steroids / Cortisone Yes No If Yes Please Describe _________________________
Steroids / Cortisone Ceased / Last Dose _________________________________________________________
Cytotoxic Medication Yes No If Yes Please Describe __________________________
Cytotoxic Medication Ceased / Last Dose ________________________________________________________
Prescribed Medication List ___________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Non Prescribed / Herbal Medication List ________________________________________________________
_________________________________________________________________________________________
Infections
Assessment
Overseas Travel within previous 10 days Yes No If Yes Please State __________
_________________________________________________________________________________________
Inpatient another Hospital within previous 2 months Yes No If Yes Please State __________
_________________________________________________________________________________________
MRSA / Golden Staph
(Multi / Methicillin Resistant Staphylococcus Aureus) Yes No If Yes Date ________________
VRE
(Vancomycin Resistant Enterococci) Yes No If Yes Date ________________
HIV / AIDS Yes No If Yes Date ________________
Hepatitis Yes No If Yes Date ________________
Pituitary Hormone Injection Before 1986 Yes No
Neurosurgery Before 1990 Yes No If Yes Provide Details _______
_________________________________________________________________________________________
Family History Creutzfeldt-Jakob Disease Yes No If Yes Provide Details ________
_________________________________________________________________________________________
I _________________________ have read the above and certify that the information given is correct and true
to the best of my ability. Signature:__________________________________ Date:_____________
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HEALTH ASSESSMENT (National Asthma Council Australia)

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Completed 9 December 2020

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