Dr Andrew Hunt BMed, FANZCA Pre-anaesthesia Questionnaire

Please complete the following questions to the best of your knowledge.

This enables Dr Hunt to care for you safely and provide the best tailored anaesthetic to your needs.

Your personal information and medical history are strictly confidential and the transmission of this information is encrypted for security.

Dr Hunt will receive this information electronically and will contact you prior to your procedure as required.

Periodically Dr Hunt sends patients a follow up questionnaire to gain feedback in order to continually improve his practice and care for patients.

Once completed, to send the form please press 'Send to Dr Hunt' at the bottom of the screen.

Following that you will be re-directed to Dr Hunt's website for more information regarding your anaesthetic (https//www.drandrewhunt.com)

Personal Information

Name

Height (approximate)

Weight (approximate)

Occupation

Date of Procedure

Operation or Procedure planned

Anaesthesia History

Please list any previous operations or procedures requiring anaesthesia?

Problems with anaesthesia? e.g. Allergies, severe reactions, nausea or vomiting, intensive care admissions, trouble inserting a breathing tube

Problems in your family with anaesthesia?

e.g. Life threatening emergencies

Do you have any allergies?

e.g. Medications, Food, Tapes

Please list all your medications

Medical History Please lists current and previous problems in the following areas

Heart Problems?
e.g. Heart attacks, Hypertension (high blood pressure), Coronary stents, AF

Lung Problems? e.g. Smoking related lung disease, Asthma

Sleep Apnoea?
e.g. Do you use a CPAP machine, stop breathing at night, snore

Kidney or Liver Problems?

Central Nervous System Problems?
e.g. Strokes, TIA, Epilepsy, Weakness, Numbness, Spinal Cord Injury

Blood Clotting or Bleeding Problems?

Do you get reflux or heartburn?

Endocrine Problems? e.g. Diabetes, Thyroid

Severe or long term pain? e.g. Back pain

Other?

Please select the most appropriate response from the below options

Smoking?

Alcohol Consumption?

Recreational Drug Use?

Exercise Tolerance. I can

Do you have dentures, loose teeth, caps, crowns or expensive dental work?

Are you a pensioner, veteran or hold a health care card?

Please list your main concern regarding your anaesthetic