Patient Health Questionnaire

PLEASE COMPLETE THIS FORM AND RETURN TO THE CENTRE AS SOON AS POSSIBLE.

Full Name *

Date of Birth *

Medicare Number: *

Medicare Expiry Date: *

Southern Day Surgery has given me a copy of: *

The Charter of Healthcare Rights and I understand my rights and responsibilityDetails on how to make a suggestion or commentHealth Information Collection Disclosures

What matters to you today in regards to your admission (other than improving your sight)?

Do you have ambulance cover? *

YesNo

If you answer NO to Ambulance Cover you agree to cover the charges if an ambulance emergency transfer is required.

Ambulance Member Number: *

Signature *

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Date Signed *

ADMISSIONS DETAILS

Admission Date : *

Surgeon:

Surgical Procedure:

Patient's Date of Birth *

Country of Birth *

Resident of Australia? *

YesNo

Are you of Aboriginal Torres Strait Islander origin? *

NoYes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal & Torres Strait IslanderDecline to answer

Primary language spoken?

Do you require an interpreter?

YesNoCarer

Next of Kin

NEXT OF KIN: FIRST CONTACT

Name *

Relationship to Patient *

Best Contact Phone *

ADDITIONAL CONTACT PERSON

Name

Relationship to Patient

Best Contact Phone

The person collecting me after surgery is (Name): *

Contact No: *

The person staying with me overnight after surgery is (Name): *

Contact No: *

Medical & Health History

Previous Cardiac/Respiratory Surgery

What is your current Weight? (kg) *

What is your current Height (cm)? *

Do you have any family members who have had a bad reaction to an anaesthetic (eg. Malignant Hyperthermia)?? *

YesNo

Current Prescribed Medications

Medication Name

Amount?

How often each day?

Any Additional Medications

Medication Name

Amount?

How often each day?

Vitamins and Herbal Remedies

Suppliments

Fish OilTurmeric

Do you take Blood Thinning Drugs? *

NoYes

If Yes, please select which medication:

Aspirin (Cartia)Clopidogrel (Plavix)Co-PlavixApixaban (Eliquis) Rivaroxaban (Xarelto)WarfarinOther

If Other:

Allergies

Are you allergic to any Antibiotics? *

No, I am not Allergic to AntibioticsPenicillinCefazolin Amoxicillin ErythromycinSulphur DrugsCefalexinOther (please detail)

Other Antibiotic:

Are you allergic to any lotions? *

No, I am not allergic to any lotionsBetadineChlorhexidineOther (please detail)

Other Lotion:

Are you allergic to tapes? *

No, I am not allergic to any tapesTegaderm Micropore ElastoplastOther (please detail)

Other Tape:

Are you allergic to any forms of Pain relief? *

No, I am not allergic to any pain reliefMorphine  EndoneTramadolOther (please detail)

Other Pain Relief:

All Other Medication you allergic too:

Endocrine (Diabetes/Thyroid) History

Do you take diabetic tablets? *

NoYes, FlozinYes, Ozempic

Do you take insulin? *

NoYes

Do you have a thyroid condition? *

NoYes (not Medicated)Yes (Medicated)

Cardiac History

Do you have high blood pressure? *

NoYes (not medicated)Yes (I am medicated)

Have you had a heart attack? *

NoYes

If yes, when (date)?

Cardiac Stent? *

NoYes

Do you have an irregular heart beat? *

NoYes

Have you had cardiac bypass or valve surgery? *

NoYes

Do you have a pacemaker/defibrillator? *

NoYes

Name of your Cardiologist:

Respiratory History

Do you have respiratory problems? *

NoYes, asthmaYes, emphysemaYes, chronic cough

Do you get shortness of breath? *

NoYes

Can you lie flat? *

NoYes

Do you have sleep apnoea? *

NoYes

Use CPAP? *

NoYes

Use home oxygen? *

NoYes

Gastrointestinal History

Do you have reflux? *

NoYesHiatus HerniaStomach Ulcers

Have you had gastric bypass surgery? *

BandSleeveOther

Year of Surgery

Do you have a kidney disorder? *

NoYesDialysis Fistula

Type of Kidney Disorder:

Do you have a liver disease? *

NoYes

Type of Liver Disease:

Do you have a colostomy/ileostomy? *

NoYes, colostomyYes, ileostomy

Suprapubic Catheter/ileal conduit? *

NoYes, suprapubic catheterYes, ileal conduit

Neurological/Brain/Spine History

Do you have any issues with memory/cognitive impairment or had any episodes of delirium? *

Have you had a stroke? *

NoYes

Do You have Parkinson's? *

NoYes

Do you have Dementia? *

NoYes

Do you have epilepsy? *

NoYes

Do you have a tremor? *

NoYes

Do you have Alzheimer's? *

NoYes

Do you have current mental health conditions? *

NoYesAnxietyDepression

Are you under the care of a Mental Health Practitioner? *

NoYes

Have you had any episodes of Self Harm? *

NoYes

Do you have an Enduring Power of Attorney (Medical)? *

NoYes

If, yes, please provide documentation to the clinic.

Other Health Concerns

Have you had cancer? *

NoYes

Type of Cancer?

Currently undergoing treatment?

NoYes

Do you have Lymphoedema? *

NoYes

Where?

Any other serious medical condition?

Female Patients Only

Is there a possibility that you may be pregnant?

NoYes

Are you currently breast feeding?

NoYes

Male Patients Only

Do you currently have a prostate condition?

NoYes

Are you currently having treatment for your Prostate?

NoYes

Lifestyle

Do you require a special diet? *

NoVegetarianVeganGluten FreeLactose FreeFructose FreeOther Food Sensitives

Do you drink alcohol? *

NoYes

What is you daily/weekly intake of Alcohol?

Do you smoke? *

NoYes

Amount of cigarettes per day?

Do you use a walking aid? *

NoYes, Walking Stick Yes, WalkerYes, Wheelchair

Can you stand and transfer to a patient trolley? *

NoYes

Do you have impaired vision or hearing? *

NoYes, my vision is impaired Yes, my hearing is impaired I wear hearing aids

After your eye operation will you or a carer be able to instil your eye drops? *

NoYes

Agreement

I agree that the information provided within this form is true and correct to the best of my ability.

Signed: *

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Date: *

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