Pre-Operative Questionnaire – Hanrahan Anaesthesia

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Step 1 of 8 - Consent

Welcome!

You've received a link to this questionnaire because you're planned for a procedure requiring anaesthesia or sedation. This questionnaire allows you to share important information with your anaesthetist in order to tailor your care to you.

You may have already provided information to your surgeon or hospital. I apologise for the repetition, but confidentiality is a priority and it's generally safer to rely on first hand information.

I've aimed to make submitting this as easy as possible. If you already have a document with your medical history, you can upload it on the last page of this questionnaire. You can also take and attach a photo of your medication list rather than type it.

You don't need to retype information that's included in files you attach, but please read and consider all the questions and comment "see upload" if the answers are in your uploaded files.

You can pause and come back later or switch to a different device (eg start on your phone and finish on your computer). To do this click on the Save and Continue Later text at the bottom of the screen. You'll send yourself a link which you can use to continue from where you were up to.

Please continue the form right up until the end where you will see an ORANGE SUBMIT button. Not all information is sent unless you press this.

Information shared via this questionnaire is secure, and remains confidential between you, your anaesthetist, your surgeon and your treating team. Aspects may be documented in your hospital record unless you advise otherwise.

Do you provide consent for your Anaesthetist to contact your other doctors and review your medical records and test results for the purpose of tailoring your anaesthetic for the planned procedure?

Please Confirm Your Consent to Selectively Share Your Medical Information*

Yes

To use this form you'll have to consent to proceed.

If you're not happy to provide that consent, please e-mail me at
pre-op@drrosshanrahan.com

Enter Your First and Last Name*

Preferred Name (if different to above)

If you prefer to go by a different name, enter that here

Date of Birth*

Please enter as DD/MM/YYYY

Weight*

(Kg or stone are fine)

Height*

(Centimeters or feet are fine)

Patient age is under 18 years. Please include some carer details...

Name of Parent/ Guardian Responsible for Child

Relation of Carer to Child

Address
Street Address Suburb State Post Code

Preferred Phone Number

Preferred Email Address

Please leave off the "+61" international code for your mobile number, and just start with "04........."

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Preferred Phone Number with International Code

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Medicare Number

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Private Health Insurer Name

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Private Health Insurer Number

There are still incomplete required fields on this page.

What is your Surgeon’s name?
What's your Planned Procedure Date?*
DD slash MM slash YYYY

Please enter as DD/MM/YYYY
Please Confirm what Procedure You're Expecting to Have.
If relevant, include which SIDE, ie LEFT or RIGHT.
There are still incomplete required fields on this page.

What (if any) Previous Operations or Procedures Have You Undergone?
Have you had any problems with previous Anaesthetics?
(include any problems family members have had)
How Physically Active Are You?
Describe the most strenuous activity you've done in the last couple of months. What stops you doing more? Do you get out of breath or chest discomfort. Do you just get tired. Does another problem limit your activity?
Questions Related to Your Airway.

- Do you have any false teeth or dentures?

- Any dental caps, crowns or veneers?

- Any broken or missing teeth?

- Do you have a beard?

Do You Have a History of Any Medical Conditions?
If you have a serious or complex condition, please include the names of any other Doctors involved in their management.
Have You Had Any Recent Coughs, Colds or Other Infections?
If you've needed antibiotics or treatment in hospital in the last month or two, include details here.
COVID Related Questions

Timing of any recent COVID infection may have implications for anaesthesia and surgery.
Have you been diagnosed with COVID in the past 2 months?

Yes

No
How Long Ago Was Your COVID Diagnosis?
Do You Feel Completely Recovered From Your COVID Infection?
Some Screening Questions

Before you continue, please review the following lists to make sure you haven't missed anything.
Heart Conditions
Have you ever had:
- Heart attacks
- Angina or chest pain on exertion
- A heart murmur
- An irregular heart rate or palpitations
- 'Fluid on the lungs' (pulmonary oedema)
Heart Conditions
I have none of these heart conditions OR I have already included details above
Lung Conditions
Have you ever had:
- Asthma
- Emphysema or chronic bronchitis
- A recent chest or throat infection
- Previous smoking for more than 5 years
- Any current smoking
- Obstructive sleep apnoea
Lung Conditions
I have none of these lung conditions OR I have already included details above
Gastointestinal Conditions
Have you ever had:
- Heartburn or reflux
- Stomach ulcers
- Liver problems
Gut Conditions
I have none of these gastrointestinal conditions OR I have already included details above
Other Conditions
Have you ever had:
- Diabetes
- Thyroid disease
- Seizures
- Strokes/ TIAs
- Chronic pain conditions
- Kidney disease
- Is there any chance you could be pregnant?
Other Conditions
I have none of these other conditions OR I have already included details above
If you do have any of these conditions, but haven't mentioned them yet, please add something about them to one of the fields above.
Please check the boxes to confirm you have reviewed all the screening questions before continuing to the next page.

Are You Allergic or Intolerant of Any Medications?
Describe what reaction you suffer.

Please List Your Current Medications and Doses.
- Skip this if you take no medications

- Don't forget Injections (insulin, Ozempic, Wegovy etc), Puffers (Ventolin etc) or Medication Patches (Norspan etc).

- If you have taken any weight loss injections (eg Ozempic, Wegovy, Mounjaro etc) in the past 3 months, please include this and specify the date of your last dose. These medications are also used for reasons other that weight loss (eg diabetes) but the precautions still apply.

- Extra space will appear if you enter more than 4 medications.

- Alternatively, you can attach a list or a photo of a medication list below. If uploading a list, please check it is complete, as injections etc are sometimes missing from GP summaries or webster packs etc..
Medication Name
Medication Dose
When taken (morning/night etc)

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Med Screen
Uses Copy Cat Plug-in to duplicate contents of list field to a paragraph field to facilitate conditional logic. Configured via CSS class added to medication field. See https://gravitywiz.com/documentation/gravity-forms-copy-cat/
Important Fasting Advice Related to Your Medications

One of your listed medications above looks like it belongs to a class of medications called "GLP-1 Receptor Agonists". Common examples are Ozempic, Wegovy, Mounjaro Trulicity and Saxenda.

These medications are important to manage carefully around surgery, as they prolong the amount of time you need to fast to be safe for general anaesthesia or sedation.

If you are taking one of these medications you'll need to go on a "clear fluid" only diet for the FULL DAY BEFORE the day of your operation, as well as the morning of the operation itself. Solid food and milk can remain in your stomach for many hours when taking these medications which can become a risk for surgery.

There's a good summary from the College of Anaesthetists describing the fasting rules at this link:

GLP1ra Patient Advice.

Please have a read of it. You should get sent a copy of this message emailed to you once you complete this form as well.
Medication List or Photo

Drop files here or

Max. file size: 15 MB, Max. files: 4.

You can upload a medication list instead of typing your medication list if you prefer

Do you have any particular questions or concerns about your Anaesthetic you wanted to ask?
Uploads

You can use this section to attach files or images about your medical history.

If you are completing this form on a smart phone you can take and add photos with the phone camera.

If you're using a computer, and want to add a photo with your phone, you can switch to your phone by pressing the "Save and Continue Later" button at the bottom of this page, and then sending an SMS to yourself to finish the questionnaire with your phone.
Attach Files (max 4)

Drop files here or

Max. file size: 25 MB, Max. files: 4.

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Days Until Procedure

Final Confirmation of Details

These three fields are particularly important to have correct.

Just make sure there aren't any typos, click 'submit' and you're done!
DATE OF BIRTH
DD slash MM slash YYYY

Please enter as DD/MM/YYYY
PHONE NUMBER
EMAIL ADDRESS