Fillable Steps to completing this questionnaire, 1. Save questionnaire (National Asthma Council Australia)

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Steps to completing this questionnaire, 1. Save questionnaire (National Asthma Council Australia)

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EMR: Perioperative / Procedure_Preadmission_Patient Information and Health Questionnaire
Date Created:
Aug 2020
Page 1 of 4
Printed From Intranet
PATIENT INFORMATION AND HEALTH QUESTIONNAIRE
MR
E34a
Alfred
Sandringham
Caulfield
UR
Given Name*
Gender: Female Male
*mandatory fields
Steps to completing this questionnaire,
1. Save questionnaire to your computer
2. Answer questions
3. email to electiveservices@alfred.org.au
4. or post to: Patient Services Centre, Alfred Health,
PO Box 315, PRAHRAN VIC 3181
• To help identify any health problems that may need treatment before your procedure, it is
important to select all conditions relevant to you and provide correct information.
• Alfred Health must receive this document within the next 7 days, to ensure no delay or
cancellation with your procedure.
• If you have questions – call 9076 0359 between 8:00am & 4:30pm Monday to Friday
• Your GP may be able to provide assistance if you are unable to complete this questionnaire.
Clinic / Speciality attending
Home Address
Postcode
Phone Mobile
Home
Email
Medicare Number
Expiry
Do you need an interpreter to assist in discussing medical information
Yes No
If yes, language
Aboriginal or Torres Strait Islander
Yes ____________________________________________
No Not specified
Do you have an advance care directive
Yes No
If yes, provide a copy
Do you have a
Medical Treatment Decision Maker
Yes No
If yes, name
Are you available at short notice
Yes No
Alternative Contact Person name
Contact Person address
Relationship
Phone
GP Name
GP Phone
GP Address
*MR E34A*
Select from list -->>>>
EMR: Perioperative / Procedure_Preadmission_Patient Information and Health Questionnaire
Date Created:
Aug 2020
Page 2 of 4
Printed From Intranet
PATIENT INFORMATION AND HEALTH QUESTIONNAIRE
MR
E34a
Alfred
Sandringham
Caulfield
UR
Given Name*
GENERAL MEDICAL CONDITIONS
Select for any conditions below, that
you have or have had
If Yes, complete any additional details relevant
High blood pressure
Managed by
Lower blood pressure
Managed by
Heart attack / Angina / cardiac disease
Specify
Irregular heart beat / Atrial Fibrillation (AF)
Managed by
Palpitations
Type
Other heart conditions
List
Pacemaker
Type
Heart valve replaced / stents
Specify
Respiratory problems / asthma /bronchitis
Do you use Nebulisers Puffers Home oxygen
Shortness of breath
Specify
Tuberculosis
Specify
Obstructive Sleep Apnoea (OSA)
Is CPAP used Yes No
Has your OSA been diagnosed with a Sleep Study?
Yes No
Where
Diabetes
Type 1 Type 2 Unsure
Do you use Insulin Tablets Diet
Managed by
Speech / swallowing problems
Specify
Any recent weight loss of more than 5kg
How much?
Any recent decrease in appetite
Specify
Epilepsy / seizures
Last seizure
Migraines / blackouts / fainting
Managed by
Stroke / mini strokes (TIAs)
Any weakness / symptoms
Blood clots / bleeding disorders / anaemia
Specify
Blood transfusions
Specify
Bowel / bladder problems / incontinence
Specify
Kidney conditions
Specify
Liver disease
Specify
Reflux / indigestion / hiatus hernia / ulcers
Specify
Mental health problems/depression/anxiety
Specify
Short term memory loss/previous confusion
Describe
Dementia / delirium / wandering
Describe
Skin conditions / existing wounds
Describe
Have you taken any prednisolone,
cortisone or steroids in the last 6 months
Name of medication
Date last taken
or still taking Yes
Chronic or acute pain
Describe
Cancer
Body Location
Date diagnosed
Females
Could you be pregnant?
Are you breast feeding?
Other medical conditions or health
problems (eg family history of cancer, arthritis)
List
EMR: Perioperative / Procedure_Preadmission_Patient Information and Health Questionnaire
Date Created:
Aug 2020
Page 3 of 4
Printed From Intranet
PATIENT INFORMATION AND HEALTH QUESTIONNAIRE
MR
E34a
Alfred
Sandringham
Caulfield
UR
Given Name*
PREVIOUS OPERATIONS / PROCEDURES / HOSPITAL STAYS
List any operations or procedures including dates and hospital where surgery was performed.
(attach a separate list if required)
ANAESTHETIC
Have you or a family member reacted to an anaesthetic? Yes No Details
Do you have any questions relating to an anaesthetic? Yes No List
Do you regularly see any specialists eg. Cardiologist. List name/s and address/s
MEDICATIONS
Do you take any blood thinning medication? Yes No
Specify
Do you take any other medications? Yes No
If yes, list all medication / tablets / puffers / eye drops / vitamins / herbal medicine that you currently take
(attach separate list if required)
Medication Name
How much (dose)
How often each day (frequency)
HEALTH INFORMATION
What is your height in cms
What is your weight in kgs
ALLERGIES Do you have any allergies. Yes No If yes, specify allergy and reaction
Latex / rubber
Medication Lotions / solutions
Tape Food Other
EMR: Perioperative / Procedure_Preadmission_Patient Information and Health Questionnaire
Date Created:
Aug 2020
Page 4 of 4
Printed From Intranet
PATIENT INFORMATION AND HEALTH QUESTIONNAIRE
MR
E34a
Alfred
Sandringham
Caulfield
UR
Given Name*
LIFESTYLE
Do you drink alcohol?
Amount
Have you ever smoked?
Current amount
Date ceased
Do you use recreational drugs?
Amount
Type
Special diet required
Specify
Impairment – vision
Aids used
Impairment – hearing
Aids used
Do you current have assistance with
Walking
Stick Frame Crutches Wheelchair Other
Hygiene
Council Other
Meals
Council Other
Medication
Dosette / webster Family Other
How many stairs you can walk up without stopping?
Two flights or more One flight Half a flight
PLANNING FOR YOUR DISCHARGE FROM HOSPITAL
↔ You must have a responsible adult to collect you on discharge from hospital ↔
DISCHARGE DETAILS
Who will collect you from hospital?
Name
Phone
Who do you live with?
Alone
With others*
In care facility or hostel*
If you live with *others or in a *care
facility, provide details
Name
Phone
Do you care for others at home
Specify
Do you receive community support
service
Specify
Do you have someone to stay with
you the night you leave hospital?
Name
Phone
Where will you go on discharge
Home Family Rehab Other
In the last twelve months have you?
• Received treatment in an overseas healthcare facility
Yes No
• Been informed that you have been a contact of someone with CPE*?
Yes No
• Been informed that you have been a contact with someone with C. auris**?
Yes No
• Have you ever been told you have CPE/ C.auris?
Yes No
*Carbapenemase-Producing enterobacteriacaea
**Candida auris
I have provided complete and accurate answers to this questionnaire to the best of my knowledge.
Name of person
completing form
Date
Person/s completing this form Patient Relative/ Carer GP Other clinician
Email completed questionnaire to electiveservices@alfred.org.au
Download
Save PDF to desktop
Email
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Completed 17 June 2021

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