Health Assessment form

Pindara Day Procedure Centre

First Name:*
Surname:*
Gender*
- Male
- Female
Email*
Admitting Doctor:*
Procedure/Surgery:*
Patient Medical / Surgical History
Physical
Age*
Height*
Weight*
BMI
Optional
Cardiac
High Blood Pressure*
- Yes
- No
High Blood Pressure Notes*
Rheumatic Fever*
- Yes
- No
Rheumatic Fever Notes*
High Cholesterol*
- Yes
- No
High Cholesterol Notes*
Clot lungs/legs (DVT/PE)*
- Yes
- No
Clot lungs/legs (DVT/PE) Notes*
Do you smoke?*
- Yes
- No
No. per day*
Anaemia (current)*
- Yes
- No
Anaemia Notes*
Heart Attack / MI*
- Yes
- No
Heart Attack / MI Date*
Chest pain / Angina*
- Yes
- No
Chest pain / Angina Notes*
Do you have a hip/heart valve replacement angioplasty/cardiac renal/stent/pacemaker defibrillator/lens implant*
- Yes
- No
Replacement or Implant Notes*
Endocrine
Diabetes*
- Yes
- No
What Type?*
- Type 1
- Type 2
IDDM/NIDDM?*
- IDDM Insulin Dependent
- NIDDM Diet/insulin/tablet
Diabetes Notes*
Respiratory
Chronic obstructive airway*
- Yes
- No
Chronic obstructive airway Notes
Shortness of breath*
- Yes
- No
Shortness of breath Notes*
Asthma/Bronchitis/Hay fever*
- Yes
- No
Asthma/Bronchitis/Hay fever Notes*
Pneumonia/Tuberculosis*
- Yes
- No
Pneumonia/Tuberculosis Notes*
Sleep Apnoea*
- Yes
- No
Sleep Apnoea Notes*
Do you have a cough, cold or sore throat?*
- Yes
- No
Cold/Sore throat/Flu Notes*
Vascular
Peripheral Vascular disease*
- Yes
- No
Peripheral Vascular disease Notes*
Pressure Ulcer*
- Yes
- No
Where:
Pressure Ulcer Notes*
Intestinal Tract
Indigestion/Reflux*
- Yes
- No
Indigestion/Reflux Notes*
Bowel disease*
- Yes
- No
Bowel disease Notes*
Kidney disease*
- Yes
- No
Kidney disease Notes*
Liver disease*
- Yes
- No
Liver disease Notes*
Incontinence issues*
- Yes
- No
Incontinence issues Notes*
Bowel Issues*
- Yes
- No
Bowel Issue Notes*
Bladder Issues*
- Yes
- No
Bladder Issue Notes*
Neurological
Stroke*
- Yes
- No
Stroke Notes*
Back or neck problems*
- Yes
- No
Back or neck Notes
Epilepsy or other fits*
- Yes
- No
Epilepsy or other fit Notes*
Stress/mental health conditions*
- Yes
- No
Stress/mental health Notes*
Falls*
- Yes
- No
Fall Notes*
Sleep disorders*
- Yes
- No
Sleep disorder Notes*
Faint/dizziness*
- Yes
- No
Faint/dizziness Notes*
Medical History"
Cancer*
- Yes
- No
Cancer Notes*
Have you any reason to believe you are in a high risk group for (AIDS virus)hepatitis or HIV*
- Yes
- No
High Risk Notes*
Eczema/Dermatitis/Psoriasis*
- Yes
- No
Eczema/Dermatitis/Psoriasis Notes*
Arthritis*
- Yes
- No
Arthritis Notes*
Any other medical conditions*
- Yes
- No
Other Medical Condition Notes*
Vision/Hearing/Mobility aides*
- Yes
- No
Vision/Hearing/Mobility Aid Notes*
List details of previous surgery and dates:
Other Notes
Have you or a member of your family ever had problems with either local or general anaesthetics?*
- Yes
- No
What reaction did they have?*
Do you tend to bleed or bruise easily?*
- Yes
- No
Bleed or Bruise Notes*
Fragile skin*
- Yes
- No
Fragile Skin Notes*
Females; are you pregnant?*
- Yes
- No
Pregnancy Notes*
Have you ever had a blood transfusion?*
- Yes
- No
Blood Transfusion Notes*
Have you ever had a reaction?*
- Yes
- No
Reaction Notes*
Do you wear a dental appliance, cap, plate, crown or bridge?*
- Yes
- No
Dental Appliance Notes*
Lifestyle
Do you drink alcohol?*
- Yes
- No
How much do you drink weekly?*
Do you or have you used recreational drugs?*
- Yes
- No
What kind of drugs and how often?*
Medication
Have you ever had any blood thinning drugs in the last week?*
- Yes
- No
Examples include Aspirin, Cartia, Warfarin, Plavix,Rivaroxaban, Pradaxa, Assasantin, Heparin, Apixaban Rivaroxaban, Pradaxa Prasugrel, Ticagrelor
When, how much and what kind of blood thinning drugs?*
Are you taking any cytotoxic/chemotherapy drugs*
- Yes
- No
What cytoxic/chemotherapy drugs?*
Do you take any unprescribed drugs or other substances?*
- Yes
- No
In particular; fish oil, garlic, echinacea capsules
What unprescribed drugs?*
Have you had any cortisone/steroids in the past 3 months?*
- Yes
- No
What tablets, injections or cream?*
Current Medication
Drugs - attach list if necessary*
- Yes
- No
Current Medication*
Name Dose Frequency
Allergies
Do you have any allergies or sensitivity to tapes, lotions, food (e.g. Kiwi Fruit Banana), Latex or rubber?*
- Yes
- No
Allergy and sensitivity Notes*
Do you have allergies to drugs?*
- Yes
- No
Drug allergy Notes*
Do you have any other allergies?*
- Yes
- No
Any other allergy Notes*
CJD Risk Screening
Do you have a family history of 2 or more first degree relatives with Creutzfeldt- Jakob Disease or other undiagnosed neurological illness?*
- Yes
- No
Neurological illness Notes*
To your knowledge did you receive pituitary hormone injections before 1986?*
- Yes
- No
Pituitary hormone injection Notes*
Did you undergo surgery on the brain (neurosurgery) before 1990?*
- Yes
- No
What type of operation was performed and who was the surgeon/hospital?*
Infectious Assessment
Do you have Multi/Methicillin Resistant Staphylococcus Aureus (MRSA/Golden Staph) or Vancomycin Resistant Enterococci (VRE) infection or any other communicable disease diagnosed within the last 14 days?*
- Yes
- No
Communicable disease Notes*
Have you travelled overseas in the past 10 days?*
- Yes
- No
Where to and how long?*
Have you been an inpatient in another hospital in the last 2 months?*
- Yes
- No
What surgery and when?

Health Assessment Form

Patient Medical / Surgical History