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Pre-Assessment Questionnaire

    Completing Your Questionnaire

    We are delighted that you have chosen Weymouth Street hospital for your operation. We would be grateful if you would spend a few minutes completing this questionnaire which will be reviewed by our Pre-assessment Nurse. She will liaise with your consultant anaesthetist to decide whether any further tests or investigations are needed and to ensure your anaesthetic is the safest possible whilst avoiding the risk of cancelling your operation on the day.

    If you have any questions, please contact the Pre-Assessment Nurse on 0203 075 2365.

    Personal Details

    Title *

    Your First Name *

    Your Surname *

    Date of Birth (dd/mm/yyyy) *

    Email *

    Please provide your mobile number *

    Proposed Operation *

    Under which surgeon? *

    Date of Operation (dd/mm/yyyy) *

    Your insurance company if you are claiming fees back

    About You

    Do you wear contact lenses?

    Any body piercings?

    Any loose teeth, crowns or plates?

    Your weight (in either kilograms or stones) *

    Your height (in centimeters or inches) *

    Surgical History

    Have you ever been to Weymouth Street Hospital before?
    YesNo

    Have you ever had an operation? *

    If Yes, please list your previous operations

    Have you ever had a general anaesthetic? (i.e this is where you have been unconscious)*

    When was your last general anaesthetic (dd/m/yyyy) ?

    Have you or a relative ever had a problem with an anaesthetic?

    Who had the problem? Yourself, a parent, grandparent etc.

    Asthma

    Have you ever suffered from asthma? *

    Please tick all that apply:

    Please give further details if you answered 'Yes' to the last question.Please include dates (dd/mm/yyy)

    Respiratory

    Do you have any lung problems?
    (Include chronic diseases and shortness of breath) *

    Please tick all that apply:

    Please provide any further information

    Obstructive Sleep Apnoea

    Do you suffer from Obstructive Sleep Apnoea ? *

    Cardiovascular

    Have you ever had heart disease or high blood pressure?*
    Please include investigations such as cardiac catheterisation, pacemakers and heart operations

    Please tick all that apply:

    Do you currently have any of the following?

    Please provide as much information as possible.
    The dates and results of any investigations would be helpful. (dd/mm/yyyy)

    Renal

    Have you ever had kidney, urinary or prostate problems?
    Women can exclude up to 3 urinary tract infections *

    Please tick all that apply:

    If you are male, do you have prostate problems.
    Frequency, poor stream, difficulty passing urine, getting up at night to urinate ?

    Please tick if you have you had:

    Please provide as much information as possible.

    Hepatic

    Have you ever had liver disease? *

    Please tick all that apply:

    Please provide as much information as possible.

    Pancreas

    Have you ever had pancreatitis?
    Please include cysts and pancreatic cancer *

    Please provide as much information as possible.

    Gastrointestinal

    Have you ever had indigestion or stomach problems? *
    This includes reflux, heartburn and ulcers

    Please tick all that apply:


    Please provide as much information as possible.

    Diabetes

    Have you ever had diabetes? *
    Please include diabetes in pregnancy

    Please tick all that apply:


    Please provide as much information as possible.
    If you are on insulin, this will need to be modified before your operation and the Pre-assessment nurse will contact you

    Neck problems

    Have you ever had neck problems
    Please include trauma, ankylosing spondylitis and an increasingly stiff neck? *

    Please tick all that apply:


    Please provide as much information as possible.

    Clotting

    Have you had bleeding problems or clots? *
    This includes DVT, pulmonary embolus, Factor V Leiden and Haemophilia

    Please tick all that apply:

    Please provide as much information as possible.

    Haematology

    Have you had anaemia, blood problems or leukaemia?
    Please include sickle cell, thalassaemia and other inherited problems *

    Please tick all that apply:


    Please provide as much information as possible.
    If you have a recent haemoglobin test result please provide the result

    Neurology

    Have you ever had fits, a stroke, TIA (mini stroke), brain tumor or receive treatment or seen a Neurologist? *

    Please tick all that apply:

    Please give further details.

    Mental Health and Memory Loss

    Have you ever had bipolar disease (depression), schizophrenia, claustrophobia or memory loss? *

    Please tick all that apply:

    Please provide further details if possible.

    Thyroid

    Have you an under or over active thyroid? *

    Please tick all that apply:


    Please provide as much information as possible.
    IF YOU ARE ON THYROXINE PLEASE ASK YOUR GP FOR YOUR LATEST BLOOD TEST AND BRING IT INTO HOSPITAL

    Medication and Drugs

    Are you taking any medication? Have you taken steroids in the last three months?
    Please include over the counter and recreational drugs, vitamins and Chinese herbs *

    Please list all the drugs you are taking.
    The dosage would be helpful, especially if you are on insulin

    Allergies

    Are you allergic to any drugs, medicines, foods or LATEX
    Include anything that causes a rash, wheezing, difficulty breathing or anaphylactic shock *

    Please provide details.
    Please tell me the name of the drug or allergen and what reaction you had. Your GP may be able to assist you if you cannot remember.

    Infections

    Please tick if you have or have had any of the following infections

    Please tick if any of the below apply to you

    Please state the hospital or country

    Please provide as much information as possible.

    Mobility

    Have you had falls? *

    Do you have mobility problems or need mobility aids? *

    Needle Phobia

    Do you have a needle phobia? *

    Additional Details

    If there is anything else that is not covered in the questions above, which you feel we should know, please give further details below:

    Statement

    You are welcome to use the next box for any further information which has not been covered in this questionnaire. Please then type your name and press the send button. The questionnaire will go to our Pre-assessment nurse who will coordinate with your consultant anaesthetist. We will contact you if we need any further information or require any further tests. You are welcome to telephone Rachel on 0203 075 2365 if you have any questions and she can also put you in contact with your consultant anaesthetist if necessary. Thank you for your help and we hope you have a comfortable stay at Weymouth Street hospital.

    Type your name below to accept*

    Your First Name*

    Your Surname*