Specialist in Anaesthesiology & Intensive Care

Your pre-operative assessment

This takes about 10 minutes. Your answers go straight to your anaesthetist, Dr Colin Padoa, so that your anaesthetic can be planned safely. Your progress is saved securely as you go — you can stop and come back on any device.

Secure access

Enter your email address and we'll send you a secure, single-use login link.

Magic link

Email address

Open the link on this device, or on whichever device you want to fill the form in on.

Overview

A quick check that we have the basics right.

Summary

Patient

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BMI

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Procedure

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About you

Identifying and contact details.

1 · Identity

Full name (as on your ID)

Date of birth

Age

Sex at birth

Mobile numberPlease enter a valid phone number.

EmailPlease enter a valid email address.

Next of kin / emergency contact

Who will be with you at home after the procedure?

Medical aid

Plan / option

Gap cover

Height & weight

Height (cm)Height in centimetres, e.g. 172 (not 1.72).

Weight (kg)Weight in kilograms, between 2 and 350.

BMI

Your procedure

If you're unsure of something, leave it blank — the theatre list will confirm it.

2 · Procedure

Planned operation / procedure

Date of procedure

Urgency

Hospital

Surgeon

Type of anaesthetic expected

Do you have an adult to take you home?You may not drive or go home alone for 24 hours after sedation or anaesthesia.

Medical conditions

Choose No major illness to set everything below to "No" — then change any that apply.

4 · History

Do you have any medical conditions?

High blood pressure

Diabetes

Heart disease

Asthma

COPD / emphysema / other lung disease

Sleep apnoea (diagnosed)

Heartburn / reflux

Kidney disease

Liver disease

Bleeding or clotting problem (incl. previous clots)

Stroke / mini-stroke (TIA)

Epilepsy / other neurological

Thyroid disease

Anxiety, depression or other mental health condition

Any other significant condition

Pacemaker or implanted defibrillator?

Cold, flu, COVID or chest infection in the last 4 weeks?

Details of any "Yes" answers above

What symptoms led to this operation? (optional)

Sleep, breathing & airway

These help predict breathing problems during and after anaesthesia.

5 · Airway

Do you snore loudly (heard through a closed door)?

Do you often feel tired or sleepy during the day?

Has anyone seen you stop breathing or choke in your sleep?

Is your shirt collar size more than 40 cm (16 inches)?

Blood pressure, BMI, age and sex are added automatically from your answers.

Can you fit three fingers (stacked) between your front teeth?

Can you tip your head back to look at the ceiling without pain?

Loose teeth, crowns, veneers, bridges or implants?

Dentures?

Heart & fitness

How your heart and lungs cope with everyday activity.

6 · Fitness

Chest pain or tightness

Shortness of breath

Fainting or blackouts

Can you climb two flights of stairs without stopping?

Medicines & allergies

Some medicines must be stopped or adjusted before surgery — please be complete.

7 · Medicines

Do you take any regular medicines?

Blood thinners (incl. aspirin)?

Weight-loss or diabetes injections / tablets such as Ozempic, Wegovy, Mounjaro, Saxenda, Trulicity, Rybelsus — or compounded semaglutide / tirzepatide?These slow stomach emptying and can make anaesthesia unsafe if not planned for.

Tablets ending in "-gliflozin" (Forxiga, Jardiance, Xigduo, Synjardy, Glyxambi, Invokana)?

Steroid tablets (e.g. prednisone) in the last 3 months?

Herbal remedies or supplements

Any allergies (medicines, food, plasters)?

Latex / rubber allergy?

Lifestyle & preferences

Answered in confidence — this only changes how we keep you safe.

8 · Lifestyle

Smoking / vaping

Alcohol

Cannabis or other recreational drugs

Have you been told you're difficult to put a drip in?

Are you very anxious about needles?

Would you decline a blood transfusion, even in an emergency?

Anything else your anaesthetist should know?

Privacy & declaration

Please read these before you confirm. They explain fees and how your information is protected under POPIA.

9 · Consent

Opens in new tabPrivacy Notice (POPIA) Opens in new tabFees, Terms & Conditions

Name of person completing this form

Relationship to patient

Date

Your answers save securely to your account as you type. To continue later, open this page again and request a new login link — on any device.