Pre-Op Questionnaire - Dr E. Vallins

Pre-Operative Questionnaire

You will have already received/ completed a similar questionnaire for the hospital, however this is not provided to your anaesthetist prior to the day of surgery. To ensure Dr Vallins is appropriately prepared for your anaesthetic, please complete the anaesthetic pre-operative questionnaire.
The questionnaire will take 10-15 minutes to complete.

Before starting the questionnaire, please ensure you have on hand:
Your usual doctor’s contact details (GP & Specialists).
A list of your current medications.
Your weight and height.
A scanned JPG or PDF of any letters or results that you wish to send to Dr Vallins.

– Step 1 of 8

Pre-Operative questionnaire

Name *

First

Last

Are you the patient?

Gender *

Male
Female
Other

Phone

Date of Birth

Age *

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OPERATION DETAILS

Surgeon *

Hospital *

Operation *

Procedure being performed – in your own words

Date of operation

Why are you having this operation?

What symptoms or diagnoses made you decide to undergo this procedure?

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PATIENT DETAILS

Height (cm)

Weight (kg)

Are you well at present? *

Yes – I am currently well
No – I have been ill

e.g – a recent fever, cough, cold, flu, sore throat, respiratory symptoms, shortness of breath, runny nose, blocked nose, headache, body aches, muscle or joint pains, nausea, diarrhoea, vomiting, loss of smell/taste, loss of appetite, fatigue or any other illness recently.

If you have been UNWELL, please provide further details.

Have you had Covid-19? *

What was the date or your positive test

Are you vaccinated?

What symptoms did you have with covid?

Asymptomatic
Mild – Cough, cold, sore throat etc – But felt well otherwise
Moderate – Symptoms as above – But felt unwell
Severe – Hospitalised due to covid

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ANAESTHETIC HISTORY

Have you ever had an anaesthetic? *

Yes
No – I have never had a previous anaesthetic

Have you ever had any anaesthetic complications or problems?

Yes
No
Unsure

Please detail YOUR previous anaesthetic problems – e.g. severe nausea/vomiting, perioperative cardiac events etc.

Please include the name of the hospital(s) these occurred at.

Have any of your BLOOD RELATIVES had a problem with anaesthetics?

Yes
No – Not that I’m aware of

Please provide details of your BLOOD RELATIVES problems with anaesthetics.

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MEDICAL CONDITIONS

Heart and Cardiovascular

Have you had any trouble with your HEART or CARDIOVASCULAR system? (this could include hypertension / high blood pressure, chest pains, angina, heart attacks, coronary artery stents, coronary artery bypass surgery, heart rhythm problems, having a pacemaker, defibrillator, strokes or mini-strokes) *

Please provide details of any HEART or CARDIOVASCULAR problems. (Please include your Cardiologist’s name and contact details if applicable.)

Respiratory (lungs)

Have you had any trouble with your RESPIRATORY system (LUNGS)? (this could include asthma, obstructive sleep apnoea (OSA) with or without CPAP mask use, cystic fibrosis or smoking-related problems). *

Please provide details of any RESPIRATORY (LUNG) problems. (Please include your Respiratory (lung) physician’s name and contact details if applicable)

Please select which best describe your exercise tolerance (You can select more than one) *

I can walk up two flights of stairs (26-30 steps)
I can walk up one flight of stairs (13-15 steps)
I can walk more than 1km on the flat
I can walk 500m on the flat
I can walk 300m on the flat
I can walk 100m on the flat
I can walk 50m on the flat
I can walk around my house

Do you smoke?

Yes – I am a current smoker
No – I am an ex-smoker
No – I have never smoked

How many cigarettes do you smoke on an average day?

How long ago did you quit smoking?

When you did smoke, how many a day (on average) would you smoke?

Diabetes

Are you a diabetic? *

How is your diabetes treated? – Please select all that apply to you.

Insulin
Tablet
Diet

Thyroid disease

Have you ever been diagnosed with THYROID disease? *

Yes
No
Unsure

Please select any that apply to your THYROID. (multiple options can be selected).

Underactive thyroid (Hypothyroid)
Overactive thyroid (Hyperthyroid)
Previous thyroid surgery
Goitre (Have you been diagnosed with one)
Your last blood tests were within 12 months
Your last blood tests were normal

Neurological (Brain)

Have you ever been diagnosed with a NEUROLOGICAL (BRAIN) condition? (eg. stroke, TIA, Multiple sclerosis, brain aneurysm, Parkinson’s disease, Epilepsy, Alzheimer’s disease, dementia, etc.) *

Please provide details of any NEUROLOGICAL problems. (Please include your NEUROLOGIST/NEURO-SURGEON’S name and contact details if applicable)

Renal (Kidney)

Have you ever been diagnosed with a RENAL (KIDNEY) condition? (eg. poor kidney function, kidney failure etc.) *

Please provide details of any RENAL (KIDNEY) problems. (Please include your NEPHROLOGIST (KIDNEY SPECIALIST’S) name and contact details if applicable)

Haematological (blood)

Have you ever had a blood clot, bleeding disorder or excessive bleeding? (e.g. deep vein thrombosis (DVT), pulmonary embolism (PE), leukaemia, haemophilia or any other BLOOD condition). *

Please provide details of any HAEMATOLOGICAL (BLOOD) problems. (Please include your /HAEMATOLOGIST (BLOOD SPECIALIST’S) name and contact details if applicable).

Gastrointestinal

Do you have gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia? *

Please select any which apply to you (multiple options can be selected)

You suffer from acid indigestion or reflux
You previously suffered from acid indigestion or reflux but currently do not due to medication.
I’ve had a gastric band or gastric sleeve surgery.

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Medications

Do you have any allergies? (e.g. medications, antibiotics, latex, iodine, food). *

ALLERGIES – Please list all your allergies.

Do you take any regular MEDICATIONS? *

This includes all syrups, tablets, puffers, patches, sprays, injections, eye drops, vitamins and herbal remedies etc.

MEDICATION LIST (If you have a PDF/ JPG copy you can upload this instead)

MEDICATION LIST

Click or drag a file to this area to upload.

Please upload a PDF or JPEG copy of your medication list

Have you taken a course of steroids within the last 3 months that is NOT mentioned in your medication list? (e.g. prednisone, prednisolone, hydrocortisone, etc.)

Please specify the name, duration and dose of the steroids you have taken within the last 3 months.

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Teeth/ Dentition

Please select all that apply to you with regards to your teeth/ dentition *

Your own teeth (with or without fillings)
Loose tooth/ teeth
Chipped tooth/ teeth
Caps, crowns, veneers
Upper denture – FULL
Upper denture – PARTIAL
Lower denture – FULL
Lower denture – PARTIAL
Braces/ wires
Implant(s)
Bridge(s)
NO teeth

Please provide any further details of your dentition.

Neck

Do you have any limitations in the movement of your neck or problems with your neck? *

Please provide details of any neck issues you have.

Airway

Have you ever been told you have a difficult airway during a previous anaesthetic? *

Please provide information on any airway issues you have been informed about.

Please upload any documentation you have about your difficult airway

Click or drag a file to this area to upload.

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Any other comment?

If you have any other information you would like to tell Dr Vallins prior to your surgery, please write below

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Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternately, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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Email *

Pre-Operative Questionnaire

Pre-Operative questionnaire

OPERATION DETAILS

PATIENT DETAILS

ANAESTHETIC HISTORY

MEDICAL CONDITIONS

Heart and Cardiovascular

Respiratory (lungs)

Diabetes

Thyroid disease

Neurological (Brain)

Renal (Kidney)

Haematological (blood)

Gastrointestinal

Medications

Teeth/ Dentition

Neck

Airway

Other documentation

Any other comment?