"*" indicates required fields Step 1 of 3 – 10% 0% Patient Name*Contact Phone Number*Email Date of Operation* DD slash MM slash YYYY Anaesthetic HistoryHave you had any previous operations? Yes No Please list your previous operations (include year if known)Have you or your immediate family had any problems with an anaesthetic? Yes No Please list the problem you have hadHave you had COVID or any other respiratory infection in the last 4 weeks? Yes No When did you have the infection? DD slash MM slash YYYY General Health HistoryWhat is your height in metres (m)?What is your weight in kilograms (kg)?Do you have any health conditions? Yes No Provide details of your health conditionHave you had any recent hospital admissions? Yes No Please provide detailsDo you have any allergies?Do you take any regular medications? Yes No Do you have any loose teeth, caps, crown or braces?Please list your regular medicationsDo you smoke? Yes No Do you drink alcohol? Yes No If yes, provide details of how much alcohol you consume in a week*Do you take non prescription or recreational drugs? Yes No Do you regularly exercise? Yes No Would you like the anaesthetist to call you before your procedure to discuss your health and the anaesthetic in more detail? Yes No Have you had any Blood tests or other Investigations pertaining to this surgery? Please attach.Max. file size: 128 MB.Useful InformationMax. file size: 128 MB.Anaesthetic Risks*Australia is one of the safest places in the world to have an anaesthetic. Nevertheless, some patients and/or surgeries carry a higher risk because of pre-existing medical conditions. There are minor complications such as headache, dizziness, nausea and vomiting, inflammation/bruising at the injection entry point, temporary nerve damage, sore throat, hoarse voice, dry eyes or sore eyes, muscular aches, lip or tongue injury. Rare but important complications include dental damage, nerve damage, aspiration of stomach contents, pneumonia, allergic reactions, the possibility of some sensation or consciousness during the operation. Extremely rare complications include heart attack, stroke, seizure, brain damage, kidney or liver impairment and death. Remember the occurrences of these events are extremely rare. I have read and understand the above risks PhoneThis field is for validation purposes and should be left unchanged. Δ
