PRE-ADMISSION PATIENT DETAILS

TO CONFIRM YOUR OPERATION BOOKING, PLEASE RETURN THIS COMPLETED FORM TO STAWELL REGIONAL HEALTH

IN THE ENCLOSED STAMPED SELF-ADRESSED ENVELOPE TO STAWELL REGIONAL HEALTH

Mail: REPLY PAID 79337,STAWELL VIC 3380

Email: admissiondetails@srh.org.au

Fax: TO 03 5358 8520

Please complete all information and appropriate responses

PATIENT DETAILS:

Title: Mr Mrs Ms Miss Master Other (please specify):________________________________

Surname:_____________________________________

Maiden/previous surname:_______________________

Given name/s:_________________________________

Address: _____________________________________

_____________________________________________

_____________________________________________

State: _____________________ Post code: _________

Home phone number:___________________________

Work / mobile number: __________________________

Email address:_________________________________

Date of birth: ____________/____________/____________

Country of birth (if Australia, please specify state):________

_______________________________________________

Sex: ___________________________________________

Religion (if applicable) :_____________________________

Do you wish for a member of clergy to visit? Yes No

Do you require an interpreter? Yes No

If you require an interpreter, please indicate the language:

_______________________________________________

Marital status: Married Single Divorced Separated Defacto Widowed

Are you (the patient) of Aboriginal or Torres Strait Islander descent?

No Yes, Aboriginal Yes, Torres Strait islander Yes, both Aboriginal and Torres Strait Islander

Medicare number:____________________________________________________ Position on card:______________

Pension or Health Care card number (if applicable):_____________________________________________________

Repatriation (DVA) number: ____________________________________________ Gold card Other

FIRST CONTACT PERSON

Name:_______________________________________

Address:_____________________________________

_____________________________________________

Relationship:__________________________________

Home phone number:___________________________

Business / mobile phone number:_________________

SECOND CONTACT PERSON

Name:__________________________________________

Address:_________________________________________

______________________________________________

Relationship:_____________________________________

Home phone number:______________________________

Business / mobile phone number:_____________________

Date of operation (if known):______/______/______

Surgeon performing the operation/treatment:___________________________________________________________

Operation/treatment to be performed:_________________________________________________________________

Your usual Doctor/GP:____________________________________________________________________________

Address:_______________________________________________________________________________________

Phone number:_________________________________ Fax number (if known):______________________________

INPATIENT ELECTION: For this admission, do you elect to be admitted as:

Private patient – with Hospital Benefits Insurance

Private patient – self funded

Public patient (Medicare)

Department of Veterans Affairs patient

WorkCover patient

Transport Accident Commission patient

If you have elected to be treated as a Private patient with hospital benefits insurance, please complete your

health insurance details below (please provide proof of membership on admission (eg member card):

Name of fund:___________________________________________________________________________________

Membership number: _____________________________ Table:__________________________________________

Have you been a member for longer than 12 months? Yes No

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For further information please contact the Preadmission Clinic:

Stawell Regional Health

Sloane Street Stawell Victoria 3380

Phone 03 5358 8569 Fax 03 5358 8520

admissiondetails@srh.org.au www.srh.org.au

For patients having surgery at

Stawell Regional Health

Requirements for Heart (ECG) & Blood Pressure (BP) Check

You will need to have the above done at your local

doctor’s clinic before surgery if you have any of the

following:

Are over 50 years of age

Have a history of heart condition i.e. High blood pressure,

high Cholesterol or have a history of chest pain or any fainting/dizzy episodes

Are on Medication for Heart problems

You have diabetes

Þ

If you have had a recent ECG (within the last 12 months) and have had no

changes with your medical conditions, a previous ECG will be acceptable.

Please get your GP to send ECG and BP results with your

NAME, DATE OF BIRTH AND ADDRESS clearly visible on the

results to:

Stawell Regional Health

admissiondetails@srh.org.au

Fax 03 5358 8520

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DRAFT

PRE ANAESTHETIC QUESTIONNAIRE

PATIENT ID NUMBER: ___________________________

SURNAME: ____________________________________

GIVEN NAMES: _________________________________

ADDRESS:_____________________________________

D.O.B.: _______/_______/_______ SEX: ____________ Nursing staff reviewing form with patient to initial and date all entries.

What operation are you having?_____________________________________________________________________

Surgeon: ______________________________________________________ Date of procedure: ___/___/___

You are required to have responsible adult pick you up and care for you after your procedure for the first 24

hours. Your surgery may be rescheduled if this is not organised for the day of your surgery. Please provide

name of responsible person picking you up and staying with you overnight:

Name: ____________________________________ Phone number: _______________________________

Do you take any medications? Yes No

Medication name Dose Time taken

Do you have any of the following? (Please tick)

Yes No Food allergies? Name and type of reaction ________________________________________

With anaphylaxis Without anaphylaxis

(Nursing staff to complete: For all food allergies, Pre-Admission Staff to alert food services staff and dietitian, update Alert Sheet, iPM and Medication Chart. Yes No Allergies / sensitivities (including medications or other)

What reaction do you have?________________________________________________________________

Yes No An Advance Care Directive or Medical Treatment Decision Maker?

If yes, please provide us with a copy of this document on admission.

(Pre-Admission Clinic Staff to update the Alert Sheet and notify Health Information Services).

Yes No Any current or previous Heart Conditions (please specify):

________________________________________________________________________________________

Chest pain - Date of last chest pain_______________ Angina Other __________________________

Yes No Bleeding / clotting problems ____________________________________________________

Yes No Anaemia? __________________________________________________________________

Yes No A liver condition? ____________________________________________________________

Yes No Family history of bleeding / clotting problems _______________________________________

Yes No High blood pressure __________________________________________________________

Yes No Stroke _____________________________________________________________________

Yes No Lung problems needing hospitalisation ___________________________________________

Yes No Troublesome shortness of breath ________________________________________________

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PRE ANAESTHETIC QUESTIONNAIRE

PATIENT ID NUMBER: ___________________________

SURNAME: ____________________________________

GIVEN NAMES: _________________________________

ADDRESS:_____________________________________

D.O.B.: _______/_______/_______ SEX: ____________

Yes No Asthma – do you use an inhaler?, Frequency_______________________________________

Yes No Home Oxygen

Yes No Sleep apnoea, if yes do you use a CPAP machine? __________________________________

Yes No Reflux of acid or food (heartburn / hiatus hernia? If yes what type?______________________

Yes No Diabetes, Type 1 Type 2

Insulin Yes No Oral medications Yes No Diet controlled Yes No

Office use: BMI

____________

How much do you weigh? ________________kg How tall are you? _______________ cm

PREVIOUS OPERATIONS / ANAESTHETICS

Operation Hospital Year Problems /Comments

Yes No Family history of serious anaesthetic problems

_________________________________________________________________________________________

_________________________________________________________________________________________

Yes No Have you seen any other specialist doctor in the last 5 years?

Reason for seeing Dr Doctor’s Name Dr Phone Number Last Visit

Activity Level

Can you normally walk without stopping: How far can you walk on flat/level ground?

More than 2 flights stairs

2 flights stairs

1 flight stairs

Half a flight of stairs

Unable to walk

What restricts you?

No limit

Less than 1km

Do you use?

Walking stick

Frame

Wheelchair

Yes No Cortisone in the previous six months _______________________________________________

Yes No Do you have difficulty opening your mouth or have limited neck movement?

Yes No Kidney / urinary problems _______________________________________________________

Yes No Fits / blackouts / epilepsy ________________________________________________________

Yes No Do you smoke? Amount per day: _______ Have you ever smoked? Yes Quit date:_________

Yes No Have you smoked in the past? If yes, please provide details ____________________________

Yes No Do you drink alcohol? If yes, average daily intake _____________glasses

Yes No Do you have Dentures Full Part Upper, Mouth piercings Loose teeth caps / crowns?

Yes No Do you wear glasses? (Please bring case with you on the day of surgery)

Yes No Do you wear contact lenses? (Please do not wear on the day of surgery if possible)

Yes No Do you wear hearing aids? (Please leave in on the day of surgery)

Yes No Do you have a pacemaker, pins, plates, screws or prosthetics? __________________________

Yes No Do you live in? House Flat Retirement village Nursing home Special Accommodation

Caravan Other: ___________________________________________________________

YesNo Do you live alone?

YesNo Do you have problems managing self-care? Do you have family or friends who could assist

you after discharge?

YesNo If you go home the same day as your surgery, do you have transport home and someone to

stay with you overnight?

YesNo Do you have problems managing self-care? Meals on wheels Home help District

Nursing Other:______________________________________________________________

Yes No Do you have any physical / mental health problems other than your planned surgery? If yes

what are they? ________________________________________________________________

Yes No Do you have difficulties with memory or thinking eg dementia? __________________________

Yes No Have you had a transfusion of blood or blood products before? __________________________

Yes No Have you had a reaction to the blood or blood products you were given? If yes, what was the

reaction? ____________________________________________________________________

Yes No Have you been admitted to hospital in the last 6 months for treatment of an infection? If yes,

what was the infection? _________________________________________________________

Yes No Do you have any infections or any infections that you have obtained in hospital? If yes, what

was the infection? ____________________________________________________________

Yes No Have you travelled overseas recently? _____________________________________________

Yes No Have you had a fall in the last 12 months? If yes, please provide details:

____________________________________________________________________________

Yes No Have you had a pressure injury (bed sore) in the past? If yes, please provide details:

____________________________________________________________________________

Yes No Is there a possibility that you are pregnant? If yes, have you notified your surgeon? Yes No

Yes No Are you breastfeeding? _________________________________________________________

Yes No Do you have any other medical conditions not mentioned above? ________________________

Yes No Have you completed this questionnaire for yourself?

If No, what is your name and relationship with this patient?

Form completed by (print name):________________________

Signature of person completing this form: ______________________________________________

Date _____/_____/____

Clinician receiving/checking the form: ______________________ Signature:___________________

Designation:_________________________ Date ____/____/______

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PATIENT ANTITHROMBOTIC MEDICATION QUESTIONNAIRE

PATIENT ID NUMBER: _____________________

SURNAME: ______________________________

FORENAME: _____________________________

ADDRESS: _______________________________

D.O.B: _____/_____/_____ SEX: _____________

PATIENT TO COMPLETE

Are you using any of the blood thinning medications listed below (please circle yes or no)

Yes No ASPIRIN (Astrix®/Solprin®/Cartia®) Yes No WARFARIN (Coumadin®/Marevan®) Yes No APIXIBAN (Eliquis®) Yes No DABIGATRAN (Pradaxa®) Yes No RIVAROXIBAN (Xarelto®) Yes No CLOPIDOGREL (Plavix®/Iscover®) Yes No CLOPIDOGREL / ASPIRIN (Co-Plavix®) Yes No PRASUGREL (Effient®)

Yes No TICAGRELOR (Brillinta®) Yes No DIPYRIDAMOLE (Persantan®) Yes No DIPYRIDAMOLE/ASPIRIN (Asasantin®)

Yes No ENOXAPARIN (Clexane®) Yes No DALTEPARIN (Fragmin®) Yes No FONDAPARINUX (Arixtra®) Yes No HEPARIN Yes No ECHINACEA Yes No FEVER FEW Yes No FISH OILS (Fish/Salmon/Krill/Calamari) Yes No GARLIC Yes No GINGKO Yes No GINGER Yes No GINSENG Yes No St JOHNS WART Yes No VITAMIN E

If you are taking ANY of the blood thinning medications listed above, please consult

your Doctor at least TWO weeks before your procedure to gain advice on stopping

them. Please take this questionnaire with you for your Doctor to complete

the section on the back of this form.

Form completed by (print name): ______________________________________________

Relationship to patient (if applicable eg. parent): __________________________________

Signature: ____________________________________________ Date: ____/____/____

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PATIENT ANTITHROMBOTIC MEDICATION QUESTIONNAIRE

PATIENT ID NUMBER: _____________________

SURNAME: ______________________________

FORENAME: _____________________________

ADDRESS: _______________________________

D.O.B: ____/____/____ SEX: ______________

GENERAL PRACTITIONER TO COMPLETE

(If your patient has circled yes to any of the medication over the page, please assess the following questions and document appropriately)

YES NO Is this patient at a high risk of clotting if regular anticoagulant is ceased prior to this procedure

YES NO Is this patient on an antiplatelet medication for a recent Cardiac stent (if stent within the last 2 years, seek specialist advice)

YES NO Does this patient require bridging anticoagulation before this procedure? If yes please document the following:

Medication required for bridging ___________________________________

Dose required ________________________________________________

Start date of bridging medication __________________________________

YES NO INR test required If yes date of test ___________________________ Section completed by (print name): ________________________________________________

Signature: _________________________________________________ Date: ____/____/____

Place of Practice: ______________________________________________________________

SPECIALIST/THEATRE TEAM TO COMPLETE

(Please complete the following questions if a patient has had their regular anticoagulation treatment ceased prior to this procedure)

Operation being performed_____________________________________________________

Plan for anticoagulation post procedure (include date to restart regular medication, and

any bridging required)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

YES NO Does the patient require District Nursing to administer medication on discharge?

YES NO Has the patient been informed on the above plan for anticoagulation?

Section completed by (print name and designation): ___________________________________ Signature: _________________________________________________ Date: ____/____/____

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