Preoperative assessment In order to plan your Anaesthesia, it is vital to have as much information as possible regarding your medical history. Please answer the following questions to the best of your ability. Depending on your responses you may be requested to book a preoperative consult at our specialist rooms.
Name of your Anaesthetist*
Name of your Surgeon*
What is the scheduled date of your operation?* Hospital where the Operation will take place?*
Please enter your first name:*
Please enter your surname:*
Gender* Date Of Birth* Age*
Height (cm)*
Please only use numbers (no letters) and enter your height in centimetres.
Weight (kg)*
Please only use numbers (no letters) and enter your weight in kilograms.
BMI
In your own words, what type of surgery are you having?*
Example: removal of wisdom teeth.
In case we need to contact you to discuss your Anaesthetic in more detail, please provide the following contact details:
Phone Number*
Email Address
GP Name*
GP Contact Number
Are you currently under the care of any medical specialists? e.g. Cardiologist, Respiratory Physician etc.* 1. Name Of Medical Specialist*
Specialty* Please select Cardiologist Respiratory Physician Pain Medicine Renal Physician Oncologist Other
Contact Number
Are you under the care of more than one medical specialist?* 2. Name Of Second Medical Specialist*
2. Specialty Please select Cardiologist Respiratory Physician Pain Medicine Renal Physician Oncologist Other
2. Contact Number
Anaesthetic History Have you previously had surgery requiring Anaesthesia?* Please list previous operations/surgery*
Certain types of past surgery are important for your Anaesthetist to note: e.g. lap band surgery
Have you had an adverse reaction to an anaesthetic before?* For example: awareness, nausea & vomiting or difficult pain control.
Please outline the previous adverse reaction:*
Is there any family history of adverse anaesthetic reactions?* For example: post operative nausea & vomiting, malignant hyperthermia, scoline apnoea.
Please provide details of anaesthetic problems experienced by family members:*
Medical History Do you have a history of heart or blood pressure problems?* For example: high blood pressure, heart attack or angina, atrial fibrillation, pacemaker, aortic stenosis.
Check any that apply:* Other heart or blood pressure problems
We may need to contact your Cardiologist to find out more about your cardiac history and any recent testing. Please provide the following information if possible.
Name of your Cardiologist
Cardiologist's Practice Name, Suburb and Phone Number
When was your last review with your Cardiologist? (Just the year is fine)
Do you have a history of lung or breathing problems?* For example: asthma, emphysema, sleep apnoea, cold or flu.
Check any that apply:* Other lung or breathing problems
Do you have difficulty climbing two flights of stairs or walking up a hill?* This question is to assess your exercise tolerance/level of fitness.
Do you have a history of reflux, stomach ulcers or other gastrointestinal problems?* Please check any that apply:* Please indicate which best describes the severity of your reflux:* Other reflux, stomach ulcers or gastrointestinal problems*
Do you have a history of kidney of liver problems?* Please check any that apply:* Other kidney or liver problems
Do you have a history of seizures, stroke or neurological disorder?* Please check any that apply:* Other seizure, stroke or neurological disorder
Do you have a history of bleeding or clotting disorder?* For example: haemophilia, von willebrands, previous deep vein thrombosis, factor V leiden.
Please check any that apply:* Other bleeding or clotting disorder
Do you have a history of diabetes, thyroid/adrenal gland, or other hormonal disorder?* Please check any that apply:* Other diabetes, thyroid/adrenal gland or other hormonal disorder
Instructions For Diabetics (Type 1 and Type 2)
If you are diabetic and taking any of the following medications :-
Dipagliflozin containing product: Forxiga, Xigduo XR (with Metformin) and Qtern (with Saxagliptin)
Empagliflozin containing products: Jardiance, Jardiamet (with Metformin) and Glyxambi (with Linagliptin)
Then please cease these medications 3 days prior to your procedure due to the risk of ketoacidosis peri operatively.
If your sugars are poorly controlled please see your GP at least one week prior to your procedure in order to obtain a substitute medication.
If you have any concerns or questions regarding these instructions for diabetes, please contact your GP as soon as possible.
I have read and understood the Diabetes Instructions?* Do you have a history of muscle or joint problems?* For example: muscular dystrophy, rheumatoid arthritis, ankylosing spondylitis.
Please list your condition(s)*
Do you take any medications?* This includes: blood pressure medications, oral contraceptive pill, blood thinners, diabetes medications.
Please list your medications:*
Please include for each medication the name, dose and frequency.
Do you have a history of food, bandage, or drug allergy/intolerance?* Please include trigger and the type of reaction you experience. E.g. peanuts = anaphylaxis, penicillin = rash*
Are there any specific pain medications you would like to avoid due to previous side effects?* For example: nausea due to codeine, pethidine, or tramadol
Please provide details:*
Do you smoke or have you smoked in the past?* Your smoking status* Approximate number of years you have been smoking:*
Please only use numbers (no letters) and enter the number of years you have been smoking for.
Approximate number of years since you quit smoking:*
Please only use numbers (no letters) and enter the number of years since you quit smoking.
Approximate number of years you used to smoke for:*
Please only use numbers (no letters) and enter the number of years that you used to smoke for.
Average number of cigarettes per day:*
Please only use numbers (no letters) and enter the average number of cigarettes you smoke per day.
Average number of cigarettes per day you used to smoke:*
Please only use numbers (no letters) and enter the average number of cigarettes that you used to smoke per day.
Do you drink alcohol?* On average how much alcohol do you consume:* On average, how many standard drinks do you consume per day:*
Please only use numbers (no letters) and enter the average number of standard drinks you consume per day.
When you do drink, on average, how many standard drinks do you consume:*
Please only use numbers (no letters) and enter the average number number of standard drinks you consume when you do drink alcohol.
Do you take recreational drugs?* Please give details of types of drug(s) used and approximately when they were last used:*
Do you have any of the following - Airway/Dental issues? Please attach any information you feel is relevant to your Anaesthetic or Medical history. Are there any other medical conditions or concerns you have that have not been covered above?* Please provide details of other medical conditions or concerns:*
Insurance Status & Informed Financial Consent Please provide your Medicare number:*
Please enter your 10 digit Medicare number which must include your reference number as the last digit.
Please indicate your insurance status:* Please select Uninsured Private Health Insurance - with Hospital Cover Private Health Insurance - No Hospital Cover Veterans' Affairs Workers' Compensation, Motor Vehicle Insurance Australian Defence Force with DAN number Cosmetic surgery or reconstructive surgery not covered by private health insurance Overseas Health Insurance
For example: private health insurance, veterans' affairs, workers' compensation claim, or motor vehicle insurance.
There is likely to be significant out of pocket expenses for your Anaesthetic. Depending on the type of Surgery you are undergoing, you maybe eligible to recieve a rebate from Medicare.
It is likely that you will need to prepay your Anaesthetic fee, and we will arrange to contact you before your surgery.
Your anaesthetic fee will be based on the Australian Society of Anaesthetists RVG (Relative Value Guide) which takes into account:
The complexity of your Anaesthetic and Surgery
Your medical conditions and general state of health
The duration of your operation
The difference between your anaesthetic management fee and the rebates from Medicare and your private health fund is known as the "Gap" or "out of pocket expense". The amount of the Gap is dependent on which health fund you belong to and your level of cover.
As a general rule, and for most routine surgery (less than 1 hour) the Gap is less than $500.00. However if you are having major, complicated surgery the out of pocket expense may be larger. Upon request we can provide an estimate of your Gap, but please be aware that it is only a rough guide as some of the circumstances surrounding your anaesthetic may be unpredictable (such as the duration of the surgery or complications).
Name of your Health Fund*
Membership Number*
If your Surgery has been approved by the Department of Veteran Affairs, your Anaesthetic fee will be fully covered.
Your Anaesthetic fees should be fully covered by your insurance claim.
Please provide the following information:
Employer
Insurance Company
Claim number
Date of injury
Your Anaesthetic fee should be covered by Garrison Health Services. Please provide the following information:
Entitled Personnel employee ID (EP ID)
Defence Approval Number (DAN)
There is likely to be significant out of pocket expenses for your Anaesthetic. Depending on the type of Surgery you are undergoing, you maybe eligible to recieve a rebate from Medicare.
It is likely that you will need to prepay your Anaesthetic fee, and we will arrange to contact you before your surgery.
Although your Anaesthetic fee maybe covered by your Overseas health insurance policy, it is likely you will need to pay for your Anaesthetic upfront and then claim this from your Insurer. We will contact you before your surgery to arrange this.
Fasting And Medication Instructions FASTING INSTRUCTIONS
Please follow these instructions as failure to do so greatly increases the chance of adverse complications under anaesthetic and as such, your procedure may be DELAYED or worse still, CANCELLED on the day.
FOOD
Please fast from all kinds of food for > 6hrs
This includes chewing gum, lollies, mints etc.
If your admission time is scheduled for the morning, it is suggested that you please fast from Midnight / 24:00.
If your admission time is scheduled closer to midday (12:00), it is suggested that you may have a 'light breakfast'. Please ensure that you have finished at least > 6hrs
(E.g. Light breakfast = toast / cup of tea or coffee.... Not bacon and eggs!)
FLUIDS
You may drink water up until 2 hrs prior to your procedure.
Note - juice / cordial / milk and 'other' liquids are classified as a FOOD and must be ceased > 6hrs
MEDICATION INSTRUCTIONS
Please take all of your medications unless advised differently by your Surgeon or Anaesthetist. You may take your medications with a small glass of water.
Special circumstances apply to:
Diabetic medications / Insulin.
Anticoagulants / 'Blood thinning' medications.
Please discuss these medications directly with your Anaesthetist at least 3 days prior
DAY SURGERY PATIENTS
If you are scheduled for Day Surgery and are expecting to go home the same day as your procedure, it is a requirement that you have a responsible family member or friend pick you up from the hospital at your discharge time. Furthermore, it is also advised that a responsible family member or friend remain at home with you to care for you overnight.
Note - It is important to understand that our 'Duty of Care' will not allow you to be discharged home in an unaccompanied Uber / Taxi etc.
I have read and understood the Fasting And Medication Instructions?* Anaesthetic Risks While Australia is among the safest nations in the world in which to have anaesthesia, receiving multiple medications and altering normal human body function carries risks. The following is a list of potential side effects and risks that patients should be aware of. Some of these risks may be increased depending on your medical history and the type of Anaesthesia used for your case.
If you are particularly concerned, you should discuss these risks with your Anaesthetist.
Common Risks of General Anaesthesia
Sore throat
Nausea and vomiting
Less Common Risks of General Anaesthesia
Minor dental damage
Awareness
Uncommon/Rare Risks of General Anaesthesia
Major allergic reaction
Heart problems
Breathing problems
Stroke or neurological injury
Do you acknowledge the risks of having anaesthesia and agree to proceed with surgery?* 