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Pre-Assessment Questionnaire

Completing Your Questionnaire

It is important you follow our recommendations on isolating between now and your admission. We recommend you to isolate for seven days prior to your procedure with the exception of having your Covid swab taken.

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 as soon as possible, which will be reviewed by our Pre-assessment Nurse.

Failure to complete this questionnaire may result in your procedure being cancelled one the day. The Pre-assessment Nurse 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.

If you have any questions, please contact the Pre-Assessment Nurse on 0203 075 2338.

    COVID 19 Information

    The following questions are designed to keep the hospital, patients and staff as free as possible from COVID-19. It is essential you answer them as truthfully as possible. We will be happy to discuss your concerns.

    Have you currently or in the previous 14 days had a temperature, cough, muscle pains, malaise, shortness of breath or loss of taste or smell?*
    YesNo

    Has anyone in your household or anyone you have been in close contact with had any of the above symptoms within the last 14 days?*
    YesNo

    Have you had a POSITIVE PCR test for COVID-19?*
    YesNo

    What date was your positive result?

    Is there any other reasons you believe you may have contracted or been exposed to COVID-19 in the last 14 days?*
    YesNo

    Personal Details

    Title *

    Your First Name *

    Your Surname *

    Date of Birth (dd/mm/yyyy) *

    Email *

    Please provide your mobile number *

    Under which surgeon? *

    Proposed Surgery? *

    Date of Operation (dd/mm/yyyy) *

    Your insurance company if you are claiming fees back

    Next of Kin Name *

    Next of Kin Number *

    About You

    Do you smoke cigarettes or vape?
    YesNo

    Do you drink alcohol?
    YesNo

    If you answered yes, how many units per week?

    Do you take recreational drugs?
    YesNo

    Do you have vision or hearing impairment? (Do you wear glasses or hearing aids?)
    YesNo

    If you answered yes, please specify (If you wear contact lenses, please bring a pair of glasses on the day of your operation)

    Have you had any dental work performed in the last 6 months?
    YesNo

    If you answered yes, please specify.

    Any body piercings?

    Any loose teeth, crowns or plates?

    Your weight (in either kilograms or stones) *

    Your height (in centimeters or inches) *

    Surgical History

    Have you ever been to Weymouth Street Hospital before?
    YesNo

    Have you ever had an operation? *

    If Yes, please list your previous operations (Please provide dates for your procedures)

    Have you ever had a general anaesthetic? (i.e this is where you have been unconscious)*

    When was your last general anaesthetic (dd/m/yyyy) ?

    Have you or a relative ever had a problem with an anaesthetic?

    Who had the problem? Yourself, a parent, grandparent etc.

    Asthma

    Have you ever suffered from asthma? *

    Please tick all that apply:

    Please give further details if you answered 'Yes' to the last question.Please include dates (dd/mm/yyy)

    Respiratory

    Do you have any lung problems?
    (Include chronic diseases and shortness of breath) *

    Please tick all that apply:

    Please provide any further information

    Obstructive Sleep Apnoea

    Do you snore*

    Have you been diagnosed with Obstructive Sleep Apnoea?*

    Cardiovascular

    Have you ever had heart disease or high blood pressure?*
    Please include investigations such as cardiac catheterisation, pacemakers and heart operations

    Please tick all that apply:

    Do you currently have any of the following?

    Please provide as much information as possible.
    The dates and results of any investigations would be helpful. (dd/mm/yyyy)

    Renal

    Have you ever had kidney, urinary or prostate problems?
    Women can exclude up to 3 urinary tract infections *

    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:

    Please provide as much information as possible.

    Hepatic

    Have you ever had liver disease? *

    Please tick all that apply:

    Please provide as much information as possible.

    Pancreas

    Have you ever had pancreatitis?
    Please include cysts and pancreatic cancer *

    Please provide as much information as possible.

    Gastrointestinal

    Have you ever had indigestion or stomach problems? *
    This includes reflux, heartburn and ulcers

    Please tick all that apply:


    Please provide as much information as possible.

    Diabetes

    Have you ever had diabetes? *
    Please include diabetes in pregnancy

    Please tick all that apply:


    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

    Neck problems

    Have you ever had neck problems
    Please include trauma, ankylosing spondylitis and an increasingly stiff neck? *

    Please tick all that apply:


    Please provide as much information as possible.

    Clotting

    Have you had bleeding problems or clots? *
    This includes DVT, pulmonary embolus, Factor V Leiden and Haemophilia

    Please tick all that apply:

    Please provide as much information as possible.

    Haematology

    Have you had anaemia, blood problems or leukaemia?
    Please include sickle cell, thalassaemia and other inherited problems *

    Please tick all that apply:


    Please provide as much information as possible.
    If you have a recent haemoglobin test result please provide the result

    Neurology

    Have you ever had fits, a stroke, TIA (mini stroke), brain tumor or receive treatment or seen a Neurologist? *

    Please tick all that apply:

    Please give further details.

    Mental Health and Memory Loss

    Have you ever had bipolar disease (depression), schizophrenia, claustrophobia or memory loss? *

    Please tick all that apply:

    Please provide further details if possible.

    Thyroid

    Have you an under or over active thyroid? *

    Please tick all that apply:


    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

    Medication and Drugs

    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 list all the drugs you are taking.
    The dosage would be helpful, especially if you are on insulin

    Allergies

    Are you allergic to any drugs, medicines, foods or LATEX
    Include anything that causes a rash, wheezing, difficulty breathing or anaphylactic shock *

    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.

    Infections

    Please tick if you have or have had any of the following infections

    Please tick if any of the below apply to you

    Please state the hospital or country

    Please provide as much information as possible.

    Mobility

    Have you had falls? *

    Do you have mobility problems or need mobility aids? *

    Needle Phobia

    Do you have a needle phobia? *

    Additional Details

    Are you under any specialists doctors or your GP for current investigations?*
    YesNo

    If you answered yes to the above, please specify.

    Will you be on your period during your hospital admission?*
    YesNo

    Are you currently breastfeeding?*
    YesNo

    If there is anything else that is not covered in the questions above, which you feel we should know, please give further details below:

    Statement

    Please type your name and press the send button to complete your questionnaire. We will contact you if we need any further information or require any further tests. You are welcome to telephone our Pre-assessment Nurse on 0203 075 2338 if you have any questions. By submitting this form, you confirm the above information is true and correct record.
    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*

    Your Surname*