Patient Questionnaire





Your privacy is important to us. The information you provide is stored securely and will only be accessed by authorised Metropolitan Anaesthesia Staff.

The fields indicated with an ‘*’ are required.

Estimates of costing cannot be issued straight away. Once the completed questionnaire is forwarded to the Doctor, they will advise of the Anaesthesia fee and a staff member will be back in contact via phone or email with the Anaesthesia estimate of costing.

To help you the best way possible we encourage you to provide us as much details as possible.

Operation Details


Anaesthetist name*

Surgeon*

Hospital*

Operation*
(The procedure being performed)

Date of Operation*

Why are you having this operation?
(What symptoms or diagnosis made you decide to undergo this procedure? )

Health Fund Name

Health Fund Number

Medicare Number – 11 digits (Incl. Reference number. This is the number on the left hand side of your name)

Patient Details


Patient Name*

Gender
MaleFemale

Is this you?
YesNo

Phone Number(s)*

Your Email*

Patient’s age*
(In years – if a child use a decimal if desired eg. 2years 6months= 2.6)

Patient’s date of birth*

Height (cm)*

Weight (kg)*

Past operations/surgeries performed are

Have you or any blood relatives ever had any problems with anaesthetics in the past?
YesNo

If ‘Yes’ please specify

Do you have any allergies?
(this includes all tablets, puffers, patches, sprays, injections, eye drops, etc.)
YesNo

If ‘Yes’ please specify

Do you take any regular medications?
(this includes all tablets, puffers, patches, sprays, injections, eye drops etc.)
YesNo

If ‘Yes’ please specify

Do you have, or have you ever had, any of the following?


Any trouble with your heart or cardiovascular system? (required)
(this could include high blood pressure, chest pains, angina, heart attacks, coronary artery stents, coronary artery bypass surgery, heart rhythm problems, having a pacemaker or defibrillator, strokes or mini strokes)
YesNo

If ‘Yes’ please specify

Shortness of breath climbing less than 2 flights of stairs or whilst walking for 30 minutes on flat ground?
YesNo

Any trouble with your lungs or respiratory system?
(this could include asthma, obstructive sleep apnoea (OSA) with or without CPAP mask use, or smoking-
related problems)
YesNo

Diabetes?
YesNo

Gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia? (required)
YesNo

Thyroid disease?
YesNo

Kidney condition?
YesNo

Blood clots or excessive bleeding?
(eg. deep vein thrombosis (DVT), pulmonary embolism (PE), haemophilia, and others)
YesNo

If ‘Yes’ please specify

With regards to your teeth or dentition – what do you have?
(please select all that apply)
Loose tooth or teethChipped tooth or teethCaps, crowns, or veneersImplant(s)Bridge(s)Partial upper denturesPartial lower denturesFull upper denturesFull lower denturesYour own teeth +/- fillings only

Please indicate the pain relievers or analgesics that have worked well for you previously
Paracetamol, eg. PanadolAnti-inflammatories, eg. NurofenTramadol, eg. TramalStrong opioids, eg. OxyNormNone of the aboveOther

if ‘Other’ please specify

Please indicate the pain relievers or analgesics that you must avoid or should not use
Paracetamol, eg. PanadolAnti-inflammatories, eg. NurofenTramadol, eg. TramalParacetamol-codeine combinations, eg. Panadeine ForteStrong opioids, eg. OxyNormOtherI am not aware of any pain relievers or analgesics that I must avoid or should not use

If ‘Other’ please specify

Upload medical information
(please feel free to upload any medical reports, test results, Specialist letters or supporting information)

Other Details


Name and telephone numbers of your doctors
(GPs and Specialists)

Do you give your consent for me to contact your other doctors if required?
(to provide you with the safest anaesthetic your anaesthetist may need to contact your other doctors to obtain test results, specialist letters, or other information. This allows better understanding of your health, meaning your anaesthetic can be individualised appropriately)
YesNo

Would you like a quote or estimate of the Anaesthetic Fee pre-operatively?
YesNo, I'm happy to proceed as is

Your anaesthetist will receive all the information submitted via this questionnaire. Depending upon your answers, your anaesthetist may decide to contact you to obtain more information, or simply to discuss particular aspects of the anaesthetic. Alternatively, your anaesthetist may be satisfied with the information submitted and be ready to proceed with your anaesthetic as is.

By submitting this form you confirm the information provided is true and correct to the best of your knowledge and can be relied upon by your anaesthetist in making clinical decisions.

Is there anything else you would like to mention?
YesNo

Send me a copy of this message (email only)

Estimates of costing cannot be issued straight away. Once the completed questionnaire is forwarded to the Doctor, they will advise of the Anaesthesia fee and a staff member will be back in contact via phone or email with the Anaesthesia estimate of costing.

If the confirmation email does not appear in your Inbox please check your Junk/Spam folder