Specialist in Anaesthesiology & Intensive Care

Your pre-operative assessment

Please complete the questionnaire below as accurately as possible. The information you provide is reviewed by your anaesthetist as part of your peri-operative care and will be treated in the strictest confidence.

Secure access

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Email address

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Clinical overview

Live summary used to inform your anaesthetic plan.

Summary

Patient

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BMI

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Procedure

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Key flags

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Patient details

Basic identifying, contact and funding information.

Identity

Full name

Date of birth

Age

Sex at birth

Phone number

Emergency contact

Medical aid

Medical aid plan

Gap cover

Height (cm)

Weight (kg)

BMI

Procedure details

Details of the planned procedure and setting.

Procedure

Planned procedure

Procedure date

Urgency

Hospital / facility

Surgeon / proceduralist

Specialty

Expected anaesthesia type

Escort / support after procedure

Anaesthetic history

Any previous anaesthetic exposure or related complications.

Anaesthesia

Previous anaesthesia

Family anaesthetic problems

Blood transfusion history

Anaesthetic issues previously experienced

Anaesthetic history notes

Medical history

Major illnesses, chronic conditions and relevant systemic disease.

History

If you select No major illness known, the main medical history fields below will auto-fill as “No” where blank.

Do you have any significant medical illnesses?

Diabetes

Hypertension

Heart disease

Asthma

COPD / chronic lung disease

Sleep apnoea / CPAP

Reflux / aspiration risk

Kidney disease

Liver disease

Bleeding disorder

Stroke / TIA

Neurological disease

Mental health condition

Other significant condition

Medical history notes

Symptoms leading to surgery

Airway, cardio-respiratory & medications

Functional status, airway concerns and current treatment.

Risk

Mouth opening

Neck movement

Loose teeth / caps / veneers

Snoring

Chest pain

Shortness of breath

Exercise tolerance

Regular medication

Blood thinners

Medication list

Allergies

Social history & declaration

Substance exposure, peri-operative support and consent declaration.

Declaration

Smoking

Alcohol

Recreational drugs

Anything else we should know?

Name of person completing form

Date

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Terms & conditions

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Terms

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