SLHD Pre-Procedure Health Questionnaire Form

Pre-Procedure Health Questionnaire Form

HELP

Please answer every question as best you can.
Parents or guardians should answer for children.
If necessary, ask a relative, friend or your general practitioner (GP) to help you.
 
Concord Repatriation General Hospital       Royal Prince Alfred Hospital      

Personal Details

Male       Female       Different Term
(please specify):
Yes       No
Yes   No
Yes   No
Type of Cover  
Hospital   Extras   Hospital and Extras
Fund name
Fund number
Yes   No
Yes   No
Yes   No
Yes   No
Married   De-facto   Single   Widowed   Separated   Divorced
Yes - Aboriginal   Yes - Torres Strait Islander   Yes - both   Neither   Unknown  
Yes   No
Yes   No

Residential address

Post   Email   Text  
Same as Patient
Same as Patient

Carer Details

Same as Patient
Yes       No

Advance Care Planning

Yes       No
If yes, please bring a copy with you to all hospital appointments and on your day of surgery.

General Practitioner/Medical Centre

Patient Health

Yes     No
Yes     No
Yes     No
Yes   No  
Alone
With family
With a carer
Nursing home
Other
House/Unit
Boarding house
Hostel
Other
Yes   No  
Community Nurse
Personal care assistance
Mal preparation assistance
Home help
Other
Yes   No  
Memory
Sight
Hearing
Communication (e.g. speech)
Movement
Other
Yes   No  
Yes   No  
Yes   No  
Yes   No  
 
If yes, give details on how many stairs
Inside    

Outside  
Yes       No      
Yes       No      
Yes       No      
Bathing
Dressing
Toileting
Cooking
Cleaning
Shopping
Other
Yes       No      
Yes       No      

Medications

Yes       No
Yes       No
Please list all drugs or medications, herbal, over the counter, vitamins, supplements, puffers and eye drops and creams.
    If you have a patient medication summary from a GP/and or healthcare provider, please attach to this form
 Name of Medication   How much (dose)?   Frequency (How often)?  
>> Add
Yes       No

Medical History

Anaesthesia and Previous Surgery

  Type of procedure   Year   Hospital  
>> Add
Yes       No
Yes       No
Yes       No

Cardiovascular Systems

Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No

Yes       No
Yes       No
Yes       No
Yes       No

Respiratory Systems

Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No

Neurological System

Yes       No
Yes       No
Yes       No
Yes       No

Endocrine System

Yes       No
Type I       Type II
Yes       No
Yes       No
Yes       No

Other Health Systems

Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No
Yes       No


Yes       No
Yes       No
Yes       No

Infection Control

Methicillin-resistant Staphylococcus aureus (MRSA)
Vancomycin-resistant Enterococci (VRE)
Carbapenemase-producing Enterobacterales (CPE)
Creutzfeldt-Jakob Disease (CJD) risk
Other (please specify):

Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No

Lifestyle

Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No
Yes     No

Agreement
Collection and disclosure of information:
To provide my care as safely and quickly as possible, hospital staff may need to access previous scans, surgeons/medical notes and/or relevant test results. I give permission for staff directly involved in my care to contact my person, treating specialists, my general practitioner or other health professionals to collect or disclose my personal health information relevant to this admission for ongoing care, accreditation, and auditing purposes.

Leave the hospital:
I understand that if I am discharged on the same day as having an anaesthetic/sedation and my surgery/procedure, I should not drive a motor vehicle or drink alcohol for 24 hours. I understand that I must be accompanied home and cared for by a responsible adult for 24 hours.

Privacy Notice

NSW Health is collecting your health information for the purpose of your medical treatment and ongoing care. Your nominated general practitioner, specialist, other healthcare provider/carer may be informed of your admission and treatment and care. Your health information may be disclosed for ongoing care purposes as permitted by the NSW Health Privacy Principles. You have a right to request access to or amendment of your health information. More information is available from the hospital’s Privacy Contact Officer, the NSW Health Privacy Leaflet for Patients and the NSW Health Patient Privacy webpage.

 
Required!
 

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Page Last Updated: 20 May, 2025