PRE-OPERATIVE ASSESSMENT

HEALTH QUESTIONNAIRE
Welcome to the pre operative assessment clinic.
Here you will be seen by a pre-op nurse assessor who may ask questions
about your general health. You will also have an opportunity to ask questions
regarding your admission for your surgery, reducing any anxieties you may
have.
To help us with the assessment process we ask you to take 5 10 minutes of
your time to fill in this health questionnaire. It is important you give as much
detail as possible as it will help us to establish your medical fitness for
anaesthetic so that the procedure can proceed safely.
This questionnaire is based on a scoring system and will help us to place you
in the appropriate clinic. If you are unsure about any of the questions or having
difficulty completing the health questionnaire please ask one of the Nurses
who will be happy to help.
All information given will be treated in confidence.

Date
Pre-operative Nurse

Initial pre-operative assessment screening proforma

FOR STAFF USE ONLY
Consultant : ...

DEMOGRAPHICS

General practitioner : .
Planned procedure :

FOR PATIENT USE

Contact numbers:
Home:

..

Mobile:

..

Work:

..

Occupation:
Dates not available for surgery (e.g. holiday, family event):

Section 1 Have you ever had or do you have any of the following?
1.
2.

Heart attack
Within the last 6months

4.

NO

0
3

2
2

0
5

3
5

0
0

High blood pressure (hypertension)

If yes is it controlled?
Chest Pain / Angina
If yes is it controlled?

3.

YES

Palpitations / Irregular heart beat

If yes please describe?

5.

Heart murmur / Rheumatic fever

6.

Pace-maker / Internal cardiac device

7.

Any other heart disease? If yes, please describe

8.

Are you currently under the care of a cardiologist?

If yes please give details

PATIENT NAME

CASE NUMBER

Section 2 Have you ever had or do you have any of the following?

YES

NO

8.

If yes is it controlled? Good 1 Fair 3 Poor 5

10.

Have you had TB (Tuberculosis)?

11.

Have you ever been told that you have obstructive sleep apnoea?

12.

Any other chest disease? If yes, please describe

Asthma
If yes is it controlled? Good 1 Fair 3 Poor 5

9.

Emphysema or chronic bronchitis

Section 3 Have you ever had any of the following?

YES

NO

13.

Thyroid problems (such as over or under-active thyroid)

14.

Diabetes

1
1

0
3

YES

NO

Have you ever had a transplant?

1
5
5

0
0
0

16.

Liver disease yellowness / jaundice

17.

Excessive bleeding / bruising

18.

Blood clot Embolism Deep vein thrombosis - clotting disorder

19.

Anaemia

YES

NO

In the last 6 months

2
5
2
5

0
0
0
0

21.

Muscle disease or progressive weakness

22.

Epilepsy or fits
If yes please describe Daily 5 Weekly 3 Monthly 2 Less 1

If yes is it controlled
Section 4
15.

Have you ever had any of the following?

Kidney, bladder or urinary problems

Are you receiving dialysis?

If yes are you taking iron suppliments?

Section 5 Have you ever had any of the following?
20.

Stroke (CVA)
In the last 6 months
Mini stroke (TIA)

PATIENT NAME

CASE NUMBER

Section 6 Anaesthetic Have you ever had any of the following?

23.

24.

YES

NO

Have you ever had an anaesthetic for an operation in the past?

If yes, please describe what operation and when?

Have you or a family member had problems with a previous anaesthetic?

YES

NO

Section 7 General

25.

Do you have any problems with restricted neck or jaw movement?

26.

Do you have any other joint or arthritis problems?

27.

Have you received Growth Hormone injections before 1985, or undergone

brain/spinal surgery before 1992, or received a corneal implant?

28.

Do you suffer from a depression, anxiety state, mental illness? Please describe
below:

29.

Do you ever get any heartburn (acid running into the back of your mouth) when
bending forward or lying flat?

30.

Have you had an infection caused by MRSA (Methicillin resistant

staphylococcus aureus)?

31.

Do you see your GP regularly for any other reasons?

If yes, why?

PATIENT NAME

CASE NUMBER

32.

33.

Do you smoke now?

34.

Is there any possibility that you may be pregnant?

35.

Do you drink more than 1 1/2 pints of beer or 3 shorts or 1/2 bottle of wine per
day most days?

Do you take any regular medicines? If yes, please list name of the medicine,
the dosage and number of times a day you take the medicine.

PATIENT NAME

NO

Have you smoked within the last 5 years?

If yes, how much a day?

36.

YES

CASE NUMBER

Please indicate any of the following medications that you may be taking?
Contraceptive pill

HRT Patches

Anticoagulant tablets

Steroid tablets (prednisolone)

Herbal medication

Over the counter medication

Please describe

Please describe

Eye drops

Inhalers

Please describe

Please describe

Recreational drugs

MAOI tablets

Please describe

(You will carry a card if you do)

PATIENT NAME

CASE NUMBER

37.

Do you have allergies (such as drugs, plasters, latex, antiseptics, food stuffs
e.g. bananas, fish, nuts, eggs and pollen). Please describe allergy & also

YES

NO

describe the reaction:

Any drugs that disagree with you? Please state.

38.

39.

Please describe any other hospital admissions in the last 5 years?

Is there anything else you think the surgeon, anaesthetist or nurse should
know? If yes, describe:

PATIENT NAME

CASE NUMBER

40.

Is there any reason you will not be able to manage at home after your
operation? If yes, describe:

YES

NO

41.

Will you be taken home by a responsible adult (aged 18+) after your operation?

42.

Will you have the responsible adult at home for 24 hours to look after you?

Name.. Signature.. Date

PATIENT NAME

CASE NUMBER