Level 13, Park House, 187 Macquarie St, Sydney NSW 2000

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Home
About
- Our Team
- Clinic
- Day Surgery
- Research
Conditions
Treatments
Diagnostics
Patient Info
Contact
- Referrers
Accreditation
Privacy Policy
Doctors

Get in touch

+44 1632 96099

mymail@mailservice.com

Pre-Operative Assessment (Surgical patients only)

Contact Us

Surname

First Name

Date of Birth

Surgeon

Operation Date

Time

Approx. Weight

Approx. Height

BMI

Patient Tel/Mobiled

Free Text

Please list below all medications you are currently taking, including vitamins and alternative medicines

Current Medications

Dose

Frequency

Time(s) that you take it

Morning

Afternoon

Evening

Current Medications

Dose

Frequency

Time(s) that you take it

Morning

Afternoon

Evening

Current Medications

Dose

Frequency

Time(s) that you take it

Morning

Afternoon

Evening

Current Medications

Dose

Frequency

Time(s) that you take it

Morning

Afternoon

Evening

Current Medications

Dose

Frequency

Time(s) that you take it

Morning

Afternoon

Evening

Do you smoke?

Yes

No

Do you drink Alcohol?

Yes

No

Females - are you pregnant?

Yes

No

DO YOU HAVE ANY ALLERGIES e.g. Latex, Medications, Food?

Yes

No

Please list previous operations and approximate dates

Have you had any problems with a local or general anaesthetic previously?

Yes

No

If yes, what did you experience or what was the problem?

Do you have a family history of anaesthetic problems?

Yes

No

If yes, please give details

What are your healthcare goals that you would like to achieve at this admission?

Do you have any Healthcare needs that need to be addressed?

Yes

If yes, please give details

Do you have an Advanced Care Plan?

Yes

No

Is there a Support Person that you would like to be involved in your care and decision making?

Yes

No

Free Text

Questions relating to Creutzfeldt Jakob Disease

Do you have a family history of two or more first degree relatives with Creutzfeldt Jakob Disease or other unspecified neurological disorder?

If you have a family history of CJD you would know and have undergone genetic studies identifying if you carry the Gene that pre-disposes you to CJD

Yes

No

Have you received Human Pituitary Hormone prior to 1986? (Growth, Gonadotrophin – for infertility)

Yes

No

Free Text

A national register of those patients who have received pituitary hormone exists. Therefore all of these patients know and have received follow up counselling.

Have you had brain surgery? If so please provide further details

Yes

No

Free Text

Questions relating to Candida auris

Have you been hospitalised overseas since 2017?

Yes

No

Have you or any family members ever been confirmed as a carrier of Candida auris?

Yes

No

Free Text

Please indicate which conditions affect or have ever affected you:

Heart Trouble/Heart Attack

Yes

No

Stroke

Yes

No

Pacemaker

Yes

No

Chest Pain

Yes

No

High Blood Pressure

Yes

No

Reflux or Indigestion

Yes

No

Asthma/Breathlessness/Persistent Cough/Lung disease

Yes

No

Liver Disease/Hepatitis

Yes

No

Epilepsy/Fits/Blackout/Dizzy Spells

Yes

No

Diabetes

Yes

No

Anaemia

Yes

No

Blood Transfusion

Yes

No

Bleeding Tendencies

Yes

No

Back or Hip Problems

Yes

No

Have you taken Aspirin/Warfarin in the last week

Yes

No

Steroid/Cortisone in Last 6 months

Yes

No

Are you in a high risk group for Hep B, C, HIV?

Yes

No

Do you use any mobility aides?

Yes

No

Are you at risk of having a fall?

Yes

No

Do you have any cognitive impairment?

Yes

No

Do you have any mental health issues?

Yes

No

Do you have any skin conditions? e.g. Rashes, Blister, Cold Sores, Pressure Sores, MRSA, VRE, Compromised skin integrity

Yes

No

I have completed this questionnaire to the best of my knowledge and understand that failure to make a full disclosure may place me at undue medical risk

Thank you for contacting us.
We will get back to you as soon as possible.

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Affiliations

Accreditation
Privacy Policy

CONTACT INFORMATION

Phone: 02 9221 3755

Email: info@sydneyretina.com.au

Address: Level 13, Park House, 187 Macquarie St, Sydney NSW 2000

BUSINESS HOURS

Mon - Fri: 7:00 am 5:00 pm

Sat - Sun: Closed

We acknowledge the Traditional Owners and Custodians of the land, the Eora Nation, on which we work and pay our respects to their Elders, both past and present.

Everyone deserves the best care. We foster an inclusive culture by embracing and valuing diversity and equality for our work colleagues and patients. This philosophy extends to everyone we interact with and the communities we serve. You are valued, regardless of race, colour, sexual orientation, gender identity, religion, national origin, ancestry, physical abilities and age.

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