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PATIENT PRE-ADMISSION QUESTIONNAIRE

Please fill out all mandatory fields marked with an asterisk *

PATIENT PROFILE

Day
Month
Year
Mobile*
Home
Work

ADDRESS

Street Address
Postal Address

ENTITLEMENTS

Medicare
(10 digit card number e.g. 1234567890)
(e.g. 01/2099)
(the number next to your name)
Pension Card
(e.g. 01/2099)
DVA
(e.g. 01/2099)

PRIVATE HEALTH INSURANCE DETAILS

$

GENERAL PRACTITIONER

NEXT OF KIN / EMERGENCY CONTACT

SUBSTITUTE DECISION MAKER IF DIFFERENT TO ABOVE

Home
Mobile

ABOUT YOUR PERSONAL HEALTH INFORMATION

We acknowledge our obligations to you under the Privacy Amendment (Private Sector) Act 2000 and the Health Records and Information Privacy Act 2002. Personal health information we collect from you will be used primarily to ensure that you recieve optimal care but may also be used for other purposes. Personal health information is released under legislation to the State Health Authority, health funds and the Private Hospital Data Bureau.

PERSONAL DETAILS CONSENT



Signature*:
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MEDICAL HISTORY

GENERAL INFORMATION

Yes/No
Are you pregnant?
How many weeks?
Do you have any religious / cultural needs?
Details
Do you have an Advance Care Directive (AHD)? (if yes, please bring in a copy)
Details
Do you have a CURRENT and ACTIVE legal guardianship order in place for another person to consent on your behalf to medical procedures or treatments?
You must bring a copy of the documents with you to your appointment.

ALLERGIES

Allergy/Reaction Allergy/Reaction

SURGICAL/MEDICAL HISTORY

List and date previous surgery, gastroscopy & colonscopy or where procedure undertaken


CURRENT MEDICATIONS TAKEN (BRING MEDICATION WITH YOU WHENEVER YOU COME TO HOSPITAL)

Please list all medications below including complimentary medicines like vitamins

Drug Name Dose Frequency

HEALTH QUESTIONAIRE

Do you currently have, or have you had any of the following Yes/No
Have you, or any of your blood relatives ever had a problem with anaesthetic
Details
Difficulty swallowing, opening your mouth or moving your neck
Details
Difficulty when you lay flat on your back?
Details
Difficulty walking up more than 2 flights of stairs
Details
Dentures
Loose or chipped teeth
Details
High blood pressure
Details
Angina, Arrhythmias or palpitations
Details
Heart attack
When and what was the outcome
Heart surgery / pacemaker / defibrillator inserted
Details
Other heart problem
Details
Heartburn or acid reflux
Details
Liver disease / hepatitis / jaundice
Details
Kidney disease
Previous blood clots in the legs or lungs
Details
Bleeding / bruising disorders
Details
Anaemia / Previous blood transfusion
Any issues?
Diabetes

Usual blood sugar level
Asthma
How frequent are the attacks?
COPD / Emphysema / Lung disease
Details
Sleep apnoea
Epilepsy or fits
How frequent are the attacks?
Arthritis
Details
Do you currently smoke or vape?
When?
Have you quit smoking or vaping
When?
Do you drink alcohol?
How often and how much?
Do you take recreational (party) drugs?
What do you take and how often?
Do you suffer from anxiety, depression or emotional disorders?
Details
Have you been diagnosed with Alzheimer’s or dementia?
Details
Have you had any recent changes to your behaviour or thinking
Details
Stroke or TIA
When?
Have you had an episode of delirium or confusion after surgery?
What are the warning signs
Falls history: Have you had any falls in the last 12 months?
How many?
Do you have a fear of falling?
More information please
Do you use walking aids?
Skin integrity: Do you have skin problems such as sores, skin tears, bruises, blisters, rashes, dermatitis or pressure sores?
Details
Infection History:
Have you had COVID-19?
Date of your most recent infection
Have you ever been placed in a private room during your hospital stay due to an infection?
Have you ever been infected or colonised with a multi-resistant organism?

Do you have a virus such as
Have you been In hospital in the last 4 weeks?
Details
Have you travelled overseas in the last 6 weeks?
Where to
Other medical conditions or disabilities not already mentioned
Details
Is there anything else you would like us to know so we can assist you on the day of surgery?
Please let us know how we can help you during your admission

PLANNING FOR YOUR DISCHARGE

Yes/No
Do you live alone?
Who will stay with you overnight?
Details
Do you have care responsibilities for others?
When

SIGNATURE

Signature:
(Please use mouse or stylus to sign below.)