Adult health questionnaire

This short form takes about 5–10 minutes to complete and helps our specialists understand your medical history before your visit — if you need a hand, just contact us.

Personal info
Not required but very helpful if you know this.
Physical address
Cardio

Please tick Yes, No, or the relevant box — have you ever had or do you currently have any of the following?

High blood pressure *

Do you take blood pressure medications? *

Low blood pressure *

Angina/Chest Pain/Palpitations? *

Heart Attack? *

Coronary Surgery or procedures? *

Stent insertion *

Artificial Heart Valve *

Heart Murmur *

Implantable Cardiac
Defibrillator (ICD) *

Pacemaker *

Blood thinning medication e.g. Warfarin/Pradaxa *

Blood disorder: Bruise easily *

Blood disorder: Anaemia *

Blood disorder: Blood clots in legs or lungs *

Respiratory

Shortness of breath *

When do you experience this? *

Persistent cough *

When do you experience this? *

Asthma *

Emphysema/Chronic Pulmonary Disease (COPD)/Obstructive Sleep Apnoea (OSA) *

Diabetes *

How do you manage?

Hiatus hernia *

Heart burn *

Stomach ulcer *

Kidney Disease *

Renal Failure *

Dialysis *

Bladder problems *

Bowel problems *

Neurological

Epilepsy *

Seizures *

Stroke *

Trans Ischemic Attack (TIA) *

Blackouts *

Alzheimer's *

Dementia *

Mental health condition *

Neurological condition *

History of dura mater implants prior to 1992 *

History of Neurosurgery prior to 1992 *

Are you or have you in the past taken human derived growth hormone? *

Other

Hepatitis *

What type of Hepatitis? *

Tuberculosis *

HIV / AIDS *

Psoriasis/Dermatitis *

Skin ulcers/Current Wounds/Dressings *

Current Skin Infections *

Hospital Acquired Infections e.g. MRSA/ESBL/VRE *

Claustrophobia *

Do you smoke? *

Do you consume alcohol? *

Do you take social/recreational drugs? *

Mobility

Do you take social/recreational drugs? *

Do you have any difficulty getting yourself off a bed? *

Do you have any difficulty lying flat? *

Do you use walker / stick / wheelchair? *

Are you prone to falls? *

Are you prone to fainting? *

Do you have any implants or prostheses? *

What implants or prostheses do you use? *

Women - Are you or could you be pregnant? *

Allergies, Reactions or Sensitivities

Do you have any Allergies, Reactions or Sensitivities? *

Do you have a list you can upload with your allergies with name and reaction? *
Click to choose file. Max upload 2MB
Are you allergic to Drugs and/or Medicine? *
Are you allergic to Latex? *
Are you allergic to Iodine? *
Are you allergic to Plaster? *
Current medications

Are you currently on any medication?

Do you have a list you can upload with your medications? *
Click to choose file. Max upload 2MB
Hospital Admissions / Operations / Procedures

Have you had any hospital admissions, operations procedures during the last 5 years? *

Do you have a list you can upload with your hospital admissions, operations procedures? *
Click to choose file. Max upload 2MB
Patients undergoing General Anaesthetic or IV Sedation

Will you be undergoing General Anaesthetic or IV Sedation during your surgery? *

Have you had General Anaesthetic or IV Sedation in the past? *

What type of anaesthetic have you had in the past? *

Have you or any family member had any problems with previous anaesthetics? *

Do you suffer from motion sickness? *

What level of motion sickness? *

Do you have problems opening your mouth? *

Previous jaw problems/injuries? *

Do you have dentures / partial plates / capped or loose teeth? *

Select which apply *

Is your physical activity restricted by shortness of breath / chest pain / joint pain? *

Select which apply *

Have you or your family members had Malignant Hyperthermia during surgery? *

Do you have any specific questions you wish the Anaesthetist to answer prior to your surgery? *

Final Questions

Do you have any religious beliefs / practice or cultural needs that we should be aware of? *

Do you have any dietary requirements? *

Any other relevant of helpful information you may wish to advise us of?

How are you feeling about your upcoming procedure? *

Declaration
Questionnaire completed by:

Note: Please contact our Pre Assessment Nurse via email admissions@franklindaysurgery.com for any additional assistance or clarification regarding this questionnaire.