We are delighted that you have chosen Weymouth Street hospital for your operation. We would be grateful if you would spend a few minutes completing this questionnaire which will be reviewed by our Pre-assessment Nurse. She will liaise with your consultant anaesthetist to decide whether any further tests or investigations are needed and to ensure your anaesthetic is the safest possible whilst avoiding the risk of cancelling your operation on the day.
If you have any questions, please contact the Pre-Assessment Nurse on 07900246511.
Title * Please SelectMrMrsMissMsDr
Your First Name *
Your Surname *
Date of Birth (dd/mm/yyyy) *
Please provide your mobile number *
Proposed Operation *
Under which surgeon? *
Date of Operation (dd/mm/yyyy) *
Your insurance company if you are claiming fees back
Do you wear contact lenses? Yes (If Yes, please bring a pair of glasses into hospital)No
Any body piercings? YesNo
Any loose teeth, crowns or plates? YesNo
Your weight (in either kilograms or stones) *
Your height (in centimeters or inches) *
Have you ever been to Weymouth Street Hospital before? YesNo
Have you ever had an operation? * Please SelectYesNo
If Yes, please list your previous operations
Have you ever had a general anaesthetic? (i.e this is where you have been unconscious)* Please SelectYesNo
When was your last general anaesthetic (dd/m/yyyy) ?
Have you or a relative ever had a problem with an anaesthetic? Please SelectYesNo
Who had the problem? Yourself, a parent, grandparent etc.
Have you ever suffered from asthma? * Please SelectYesNo
Please tick all that apply: I only had asthma in childhoodI developed asthma as an adultI have had an attack in the past four weeksMy asthma is stableI have needed emergency help for an asthma attack Please give further details if you answered 'Yes' to the last question.Please include dates (dd/mm/yyy)
Do you have any lung problems? (Include chronic diseases and shortness of breath) * Please SelectYesNo
Please tick all that apply: I produce sputum every winterI have been diagnosed with bronciectasis or emphysemaI have had lung cancerI have had an operation on my lungsI get short of breath on moderate exerciseI need oxygenI have other lung problems Please provide any further information
Do you have Obstructive Sleep Apnoea or snore? * Please SelectYesNo
Do you snore loudly? Please SelectYesNo
What is your collar size? (inches)
Do you feel tired, fatigued or sleepy during the day? Please SelectYesNo
Has anyone observed you to stop breathing during your sleep? (Partners often report the person snores, then is silent for a few seconds) Please SelectYesNo
Please provide as much information as possible.
Have you ever had heart disease or high blood pressure?* Please include investigations such as cardiac catheterisation, pacemakers and heart operations Please SelectYesNo
Please tick all that apply: I have high blood pressure and / or I am taking tablets for hypertensionI have had anginaI have had a heart attackI have had heart bypass surgeryI have heart valve problems or had a valve operationI have heart failureI have or have had atrial fibrillationI have or have had other arrythmias (irregular heart beats)I have had an ablationI have an aneurysm or have had aneurysm surgery
Do you currently have any of the following? A pacemakerAn indwelling defibrillatorA plain stentA drug eluting stentA heart valve replacement Please provide as much information as possible. The dates and results of any investigations would be helpful. (dd/mm/yyyy)
Have you ever had kidney, urinary or prostate problems? Women can exclude up to 3 urinary tract infections * Please SelectYesNo
Please tick all that apply: Do you have renal failure (kidney failure)?Are you on dialysis?Have you had a kidney transplant?
If you are male, do you have prostate problems. Frequency, poor stream, difficulty passing urine, getting up at night to urinate ? Please SelectYesno
Please tick if you have you had: Prostate cancerSurgery to remove your prostateRadiotherapyChemotherapyUltrasound treatment Please provide as much information as possible.
Have you ever had liver disease? * Please SelectYesNo
Please tick all that apply: I have had jaundice (other than at birth)I have had hepatitisI have cirrhosisI have liver failure Please provide as much information as possible.
Have you ever had pancreatitis? Please include cysts and pancreatic cancer * Please SelectYesNo
Have you ever had indigestion or stomach problems? * This includes reflux, heartburn and ulcers Please SelectYesNo
Please tick all that apply: I have indigestion or heartburnI get a nasty taste and / or fluid in my mouth if I lie down or bend overI have had an endoscopy (camera investigation)I have or had an ulcerI have been diagnosed with refluxI have had surgery Please provide as much information as possible.
Have you ever had diabetes? * Please include diabetes in pregnancy Please SelectYesNo
Please tick all that apply: I have been on insulinI am on insulinI have been on diabetic tabletsI have had low blood sugar ('hypos') in the last yearMy diabetes is well controlledI have had my eyes examined in the last yearI have had a HbA1c result within the last 3 monthsI have kidney complicationsI have diabetic leg ulcers or poor blood supply in my legsMy diabetes is well controlled Please provide as much information as possible. If you are on insulin, this will need to be modified before your operation and the Pre-assessment nurse will contact you
Have you ever had neck problems Please include trauma, ankylosing spondylitis and an increasingly stiff neck? * Please SelectYesNo
Please tick all that apply: I have a painful neckI have a stiff neckI have had a whiplash injuryI have rheumatoid arthritis affecting my neckI have ankylosing spondylitisI find it difficult to look up or look behind meI have had neck surgery or injections into the spine Please provide as much information as possible.
Have you had bleeding problems or clots? * This includes DVT, pulmonary embolus, Factor V Leiden and Haemophilia Please SelectYesNo
Please tick all that apply: I have had a deep vein thrombosisI have had a pulmonary embolusI have been on anticoagulants (blood thinners)I am still on anticoagulantsI have a clotting problem such as factor V LeidenI bleed or bruise easily and have a bleeding problem such as haemophilia or factor X deficiencyI am under the care of a Haematologist Please provide as much information as possible.
Have you had anaemia, blood problems or leukaemia? Please include sickle cell, thalassaemia and other inherited problems * Please SelectYesNo
Please tick all that apply: I have had anaemia or low ironI am currently anaemicI take iron tabletsI have had leukaemia or lymphomaI have sickle traitI have thalassemia traitI have thalassemiaI have a family history of these problems but have not been testedI am under the care if a haematologistI have thalassemia Please provide as much information as possible. If you have a recent haemoglobin test result please provide the result
Have you ever had fits, a stroke, TIA (mini stroke), brain tumor or receive treatment or seen a Neurologist? * Please SelectYesNo
Please tick all that apply: I have had fitsI am currently epileptic and/or take drugs to control fitsI have had a strokeI have had or may have had a mini stroke (transient ischaemic attack)I have had brain surgeryI have had a head injury requiring intensive careI have seen a neurologist Please give further details.
Have you ever had bipolar disease (depression), schizophrenia, claustrophobia or memory loss? * Please SelectYesNo
Please tick all that apply: I have suffered from bipolar disease (depression)I have schitzophreniaI have been under a psychiatristI suffer from claustrophobiaI have memory lossI need my partner or family to help me make decisions Please provide further details if possible.
Have you an under or over active thyroid? * Please SelectYesNo
Please tick all that apply: I have an underactive thyroidI have a specific diagnosis (e.g. Hashimotos, Graves)I take thyroxineI have an overactive thyroidI have had a thyroid mass or thyroid surgery Please provide as much information as possible. IF YOU ARE ON THYROXINE PLEASE ASK YOUR GP FOR YOUR LATEST BLOOD TEST AND BRING IT INTO HOSPITAL
Are you taking any medication? Have you taken steroids in the last three months? Please include over the counter and recreational drugs, vitamins and Chinese herbs * Please SelectYesNo
Please list all the drugs you are taking. The dosage would be helpful, especially if you are on insulin
Are you allergic to any drugs, medicines, foods or LATEX Include anything that causes a rash, wheezing, difficulty breathing or anaphylactic shock * Please SelectYesNo
Please provide details. Please tell me the name of the drug or allergen and what reaction you had. Your GP may be able to assist you if you cannot remember.
Please tick if you have or have had any of the following infections
HepatitisHIVMalariaPseudomonasTuberculosis (TB)SARSMRSAWound or leg infection in past six months
Please tick if any of the below apply to you
I have an open woundContact with other communicable infections in last three monthsI am a healthcare professionalI have spent more than 24 hours in a UK or overseas hospital in the last 12 months
Please state the hospital or country
Please provide as much information as possible.
Have you had falls? * Please SelectYesNo
Do you have mobility problems or need mobility aids? * Please SelectYesNo
Please provide as much information as possible.
Do you have a needle phobia? * Please SelectYesNo
If there is anything else that is not covered in the questions above, which you feel we should know, please give further details below:
Finally, we would like to ask you a few questions regarding the recent Coronavirus outbreak.
Do you have a new continuous cough or a high temperature? * YesNo
Have you had contact with a person who has confirmed case of coronavirus in the previous 14 days? * YesNo
Have you travelled abroad in the previous 14 days even if you do not have symptoms?* YesNo
If you have answered yes to any of the above please follow Public Health England's advice which can be accessed here: https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public.
You are welcome to use the next box for any further information which has not been covered in this questionnaire. Please then type your name and press the send button. The questionnaire will go to our Pre-assessment nurse who will coordinate with your consultant anaesthetist. We will contact you if we need any further information or require any further tests. You are welcome to telephone Rachel on 07900246511. if you have any questions and she can also put you in contact with your consultant anaesthetist if necessary. Thank you for your help and we hope you have a comfortable stay at Weymouth Street hospital.
Type your name below to accept*
Your First Name*