Dr Karen Wong | Anaesthetist

Thank you for taking the time to complete your preoperative anaesthetic health assessment, I estimate it will take approximately 10 minutes to complete. This will allow me to plan the safest anaesthetic for your upcoming procedure. It will also help prevent unexpected cancellations on the day of surgery due to unforeseen health or medical issues. The data collected here is strictly confidential, it is only used for the purpose of improving your medical care.

Medical History

Patient Contact Information

Name of Person Completing Form

First Name *

Last Name *

Email Address

Contact Number *

Date of Birth *

Age at time of procedure *

Procedure Information

What is the name of your surgeon? *

What is the name of the procedure you are having? *Does not need to be medically exact

What is the date of your procedure?

In which hospital are you having your procedure? *

Medical Information

What is your gender? *

MaleFemaleOther

According to your Medicare file

Please specify

What is your weight? *Kilograms

What is your height? *Centimetres

Smoking history *

Never smokedSmoked in the past but stopped more than 3 months agoSmoked in the past but stopped less than 3 months agoCurrently smoke less than 1 pack a dayCurrently smoke more than 1 pack a day

Alcohol history *

Have you ever had an anaesthetic? *

YesNo

Have you ever had a complication from anaesthesia? *

YesNo

Please specify complication

Has a blood relative ever had a complication from anaesthesia?

YesNo

Please specify complication

Do you have high blood pressure? *

NoYes, but I do not take medication to control itYes, I take 1 medication to control it Yes, I take 2 medications to control itYes, I take 3+ medications to control it

Do you have heart disease? *

NoYes, but no longer need to see a heart specialistYes, I have seen a heart specialist within the last 6 monthsYes, I have not seen a heart specialist within the last 6 monthsYes, I have heart disease symptoms but have not seen a heart specialist

Do you have a pacemaker? *

NoYes, inserted or checked less than 12 months agoYes, inserted or checked more than 12 months ago

Do you have an implantable defibrillator or pacemaker with defibrillator function? *

YesNo

Please provide further details

Do you have diabetes? *

NoType 2, treated by dietType 2, I take 1 oral medication to control itType 2, I take 2+ oral or insulin medications to control itType 1, and require insulin (with or without oral medication)

Do you have lung disease? *

NoYes, but never required hospital admission for itYes, my last hospital admission for it was more than 12 months agoYes, my last hospital admission for it was less than 12 months agoYes, I require home oxygen to treat it

Examples: Asthma, Emphysema, Asbestosis, Fibrosis, Bronchiectasis, Pneumothorax etc.

In the last 7 days, have you had symptoms of or a confirmed respiratory infection? *

YesNo

Examples: Cough, Cold, Flu, Covid-19, Sore throat, Bronchitis, Pneumonia etc.

Please provide further details

Do you use a CPAP breathing machine at night? *

YesNo

Please provide further details

Are you able to climb 2 flights of stairs/walk briskly for more than 2km? *

YesNo, due to physical limitations (injury, arthritis, disability etc)No, due to shortness of breath, exhaustion, chest pain or dizziness

Have you ever had a blood clot or pulmonary embolism (blood clot on the lung)? *

NoYes, more than 6 months agoYes, less than 6 months agoYes, following a surgical procedure

Have you ever had a heart attack, stroke or TIA (mini-stroke)? *

NoYes, more than 6 months agoYes, less than 6 months ago

Do you have epilepsy? *

NoYes, but have not had a seizure in the last 12 monthsYes, and have had a seizure in the last 12 months

Do you have kidney disease? *

NoYesYes, and need dialysis

Please provider further details

Do you have liver disease? *

NoYes

Examples: Ascites, Cirrhosis, Hepatitis etc.

Please specify

Do you have a genetic condition? *

NoYes

Examples: Muscular Dystrophy, Down Syndrome, Haemophilia, Neurofibromatosis, Malginant Hyperthermia etc.

Please specify

Do you have any long term complex pain issues? *

NoYes

Please provide further details

Do you take any blood thinning medications? *

NoYes, Aspirin (Astrix, Cartia, Solprin, Cardiprin, Asasantin, Aspro, Disprin, Spren etc.)Yes, Clopidogrel (Plavix, Iscover, Plavicor, CoPlavix, DuoCover, Clovix, Piax, DuoPlidogrel)Yes, Warfarin (Coumadin, Merevan)Yes, new generation blood thinners (Pradexa, Xaerlto, Brilinta, Tilodene, Effient, Eliquis)

Please provide list of your medicationsInclude supplements, vitamins, alternative medicines, medicinal cannabis etc

I will advise the practice if I am taking GLP-1 or SGLT-2 medications (see Important Medication Information section for more info) *

Do you have any known drug allergies? Please list below.Skip question if no allergies

Important Medication Information

Please read this section carefully, you may be required to follow instructions if you are taking any of the listed medications:

Medication Type	Medication Names	Instructions
Biguanides	Metformin Diabex Diaformin Formet Metex	Do not cease
DPP4 Inhibitors	Alogliptin (Nesina) Linagliptin (Trajenta) Saxagliptin (Onglyza) Sitagliptin (Januvia) Vildagliptin (Galvus)	Do not cease
SGLT2 Inhibitors	Empagliflozin Systemic (Jardiance) Canagliflozin Systemic (Invokana) Dapagliflozin Systemic (Farxiga) Ertugliflozin Systemic (Steglatro) Bexagliflozin Systemic (Brenzavvy) Sotagliflozin Systemic (Inpefa)	Cease day of procedure
Sulphonylureas	Glipizide Systemic (GlipiZIDE, Glucotrol, Glucotrol XL) Glimepiride Systemic (Amaryl) Glyburide Systemic (DiaBeta, Glycron, Glynase, Glynase PresTab)	Cease day of procedure
GLP1 Agonists/Weightloss Medications	Semaglutide (Ozempic, Wegovy, Rybelsus) Dulaglutide (Trulicity) Liraglutide (Victoza, Saxsenda) Tirzepatide (Mounjaro)	Cease day of procedure AND follow diet instructions on next page

I understand *

Patients Taking GLP-1 & SGLT-2 Medications

Modified Liquid Diet

Diet to contain nothing other than:

Water
Cordial (must be clear, yellow or orange only)
Jelly (must be clear, yellow or orange only)
Fruit juice (pear or apple juice only)
Black tea, herbal tea, iced tea coffee ( no milk)
Gatorade/Poweraid sports drinks
Clear strained soup

Clear Fluid Diet

Diet to contain nothing other than:

Water
Cordial (must be clear, yellow or orange only)
Black tea, herbal tea, iced tea, coffee ( no milk)
No carbonated drinks

Instructions for patients on morning procedure list:

Timeline	Diet
72 hours before procedure	Modified liquid diet
24 hours before procedure	Clear fluid diet
Day of procedure (12am-6am)	Cease clear fluid diet and only drink small amounts of water (up to 125ml per hour)
Day of procedure (from 6am)	Nil by mouth

Instructions for patients on afternoon procedure list:

Timeline	Diet
72 hours before procedure	Modified liquid diet
24 hours before procedure	Clear fluid diet
Day of procedure (6am-11am)	Cease clear fluid diet and only drink small amounts of water (up to 125ml per hour)
Day of procedure (from 11am)	Nil by mouth

I understand *

Do you wish to provide any other health information?Examples: chronic conditions, hospital admissions, medical specialists etc.

Who is your GP?

GP practice phone number

I agree to the collection and confidentiality of my personal information in my electronic file. I authorise Dr. Wong to discuss relevant information with my healthcare team involved in my care. *

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