Pre-op Form

11. GENERAL DETAILS

22. GP DETAILS

3 3. PLANNED PROCEDURE

44. HEALTH QUESTIONNAIRE

55. PREVIOUS SURGERY

66. OTHER DETAILS

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This field is for validation purposes and should be left unchanged.

First name*

Last name*

Your Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Number*

After hours contact number

Do you have an email address?*

Yes

Your Email Address*

Email Address Confirm Email Address

Date of Birth*

Day

Month

Year

NHI number

Are you a New Zealand resident?*

Yes

Gender

Male

Female

Not Stated

Are you or could you be pregnant?*

Yes

Weight (KG)*

Height (Metres)*

GP Details

Doctors Name Practice Name

Contact number

Proposed surgery

Surgeon*

Anaesthetist

Place

Date

DD slash MM slash YYYY

ACC Claim*

Yes

Self-pay

Claim number

Insurance details

High blood pressure*

Yes

Bleeding or excessive bruising*

Yes

Previous heart attack*

Yes

Blood clots in legs/lungs*

Yes

Heart murmur*

Yes

Blood transfusion*

Yes

Palpitations or unusual beating*

Yes

Hepatitis/jaundice*

Yes

Artificial heart valve or pacemaker*

Yes

Risk of exposure to hepatitis*

Yes

Chest pains/tightness or angina*

Yes

Kidney problems*

Yes

Hiatus hernia/heartburn/indigestion*

Yes

Diabetes*

Yes

Previous rheumatic fever*

Yes

Stroke*

Yes

Asthma*

Yes

Blackouts/fainting*

Yes

Tuberculosis*

Yes

Medication for long term pain*

Yes

Emphysema*

Yes

Recreational drugs*

Yes

Persistent cough*

Yes

Steroids (e.g prednisone)*

Yes

Shortness of breath*

Yes

Joint or metal implant Arthritis*

Yes

Obstruction sleep apnoea*

Yes

Do you smoke or vape?*

Yes

Anaemia*

Yes

Do you drink alcohol?*

Yes

If you answered ‘Yes’ to any of the above, please give further details below. e.g. if you have ticked chest pains, please note the name of your Cardiologist, or if you have tested positive for Covid, please note the date when you were positive

Have you had previous surgery before?*

Yes

List

Surgery

Date

Hospital

Have you or any of your family had problems with an anaesthetic?*

Yes

Please specify (optional)

What medications (including herbal) and /or drugs are you taking?*

Medication and dose

Time taken

Do you have allergies to medication, tablets, plasters, food, LATEX and other substance?*

Yes

Please list*

Substance

Type of reaction

Are you under any regular medical specialists care e.g. Cardiologist, Oncologist*

Yes

Please specify (optional)

Have you tested positive for Covid? If yes, please note the date when, you were positive*

Yes

Please specify (optional)

Do you have a problem opening your mouth? (E.g. previous jaw problems)*

Yes

Please specify (optional)

Do you feel restricted by: Shortness of breath, chest pain, joint pain?*

Yes

Please specify (optional)

Are there any significant major illnesses, to your knowledge, among your blood relatives? e.g, muscular dystrophy, malignant hyperthermia*

Yes

Please specify (optional)

Do you suffer from any other condition, not covered elsewhere, that you feel we should know about?*

Yes

Please specify (optional)

Do you have any concerns or questions about your anaesthetic*

Yes

Please specify (optional)

Are you or could you be pregnant?*

Yes

The above details have been completed by*

Patient

Parent

Caregiver

Other

Please sign your name*

Please Note

If you have urgent queries, please contact your anaesthetist at his/her room or your surgeon.

If your anaesthetist believes there are significant risks identified in this questionnaire, he/she may contact you to make an appointment before surgery and may gather your medical information.

Please carry all your medications with you to the hospital / facility.

Any reservations

Tick if you have any reservations for your anaesthetist in obtaining your medical information.

Pre-Op Form

Please Note

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