PHOENIX HOSPITAL GROUP
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Questionnaire Pre Assesment – For Nurse

Patient Name (required)

Obstructive Sleep Apnoea details

Do you use a continuous positive airway pressure (CPAP) device to help you breathe at night?

Do you snore loudly?

Do you feel tired, fatigued or sleepy during the day?

Has anyone observed you to stop breathing during your sleep? (Partners often report the person snores, then is silent for a few seconds)

Cardiac details

Please tick all that apply:

Do you currently have any of the following?

Renal details

Please tick all that apply:

If you are male, do you have prostate problems Frequency, poor stream, difficulty passing urine, getting up at night to urinate ?

Please tick if you have you had:

Hepatic details

Please tick all that apply:

Gastrointestinal details

Please tick all that apply:

Diabetes details

Please tick all that apply:

Neck details

Please tick all that apply:

Clotting details

Please tick all that apply:

Haematology details

Please tick all that apply:

Neurology details

Please tick all that apply:

Psychology details

Please tick all that apply:

Thyroid details

Please tick all that apply:

IF YOU ARE ON THYROXINE PLEASE ASK YOUR GP FOR YOUR LATEST BLOOD TEST AND BRING IT INTO HOSPITAL

Infections details

Please give further details if you answered 'yes' to the last question Please include dates

Dietary Requirements

Statement

I confirm the above information to be true to my best ability. I understand that the information used here is for the purpose of my admission to hospital. I understand that I am responsible for the accuracy of the information given and I am aware that this is used for my procedures’ anaesthetic purpose. I am aware that a nurse will be forwarding this information onto my anaesthetist and that the nurse may contact me to go over any of the information that I have provided.

Please write your name below to confirm acceptance