SURNAME
REFERENCE
OTHER NAMES
[ ] MALE
D.O.B. ______/_______/_________
Concord Hospital
[ ] FEMALE
M.O.
ADDRESS
PRE-PROCEDURE
HEALTH QUESTIONNAIRE
LOCATION
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Please answer every question as best you can. Parents or guardians should answer for children.
If necessary , ask a relative, friend or your general practitioner to help you.
Patient’s Age:…………...…...….. Sex:………...…………….. Weight:…………...……………... Height:…..……………………….
Form completed by:
 Patient
 Other (who): …..…………………...……... Date form completed:……………………….
What health problems are you coming into hospital for?.............................................................................................................
........................................................................................................................................................................................................
What Cardiac, Respiratory or other health problems do you have now (include specialist’s name/phone numbers)?
………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………….
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What operations and/or major illnesses have you had in the past?.............................................................................................
…………………………………………………………………………………………………………………………………………...……..
BINDING MARGIN - NO WRITING
Have you be in hospital or seen a Cardiologist in the last six months (details)?......................................................................
…………………………………………………………………………………………………………………………………………………..
YES 
NO 
Do you have any allergies (medicines, sticking plaster, iodine, latex or food)? Details?
……………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………
Please list ALL drugs or medications, herbal or other therapies that you have taken in the last month:
Name:
How much (dose)
How often
Name:
How much (dose)
How often
NO  Have you taken any aspirin, anti-inflammatory or blood thinner drugs in the last two weeks?
YES 
NO  Have you taken any steroids (prednisone, cortisone) in the last six months?
YES 
NO  Are you taking oral contraceptive pill?
YES 
NO  Do you take sleeping tablets, or tablets for anxiety or nerves?
YES 
NO  Do you smoke now? How many cigarettes a day (on average)?.....................................................................
YES 
NO  In the past? Cigs/day…………… No. of years?................ When did you stop?..............................................
YES 
NO 
YES 
NO  Do you take recreational (party) drugs? Which one and how often?............................................................
Do you drink alcohol? How many “standard” drinks each day (on average)?................................................
July 11/Rev May 15
What is the MOST number of stairs you are able to climb?
(tick one):
 Four flights of stairs (two floors)
What stops you from climbing further?
 Two flights of stairs (one floor)
 Nothing
 One flight of stairs (12 steps)
………………………………………………………………….
 Around the house only
………………………………………………………………….
CRGH MR 4/0e
YES 
PRE-PROCEDURE HEALTH QUESTIONNAIRE
This form is to be completed online.
Once finished please print.
RESET FORM
SURNAME
REFERENCE
OTHER NAMES
[ ] MALE
D.O.B. ______/_______/_________
Concord Hospital
PRE-PROCEDURE
HEALTH QUESTIONNAIRE
[ ] FEMALE
M.O.
ADDRESS
LOCATION
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
YES  NO  Have you or your family had any problems with an anaesthetic? What happened?
………………………………………………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………………………………...
YES  NO  Are you very worried about having an anaesthetic? What worries you most?
………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………….
Do you have, or have had:
YES  NO  High blood pressure? For how many years?.............................................................................................
YES  NO  Chest pain on exertion or Angina? How often?...........................................................................................
YES  NO  A Heart Attack? When?................................................................................................................................
YES  NO  Frequent Palpitations? Details:....................................................................................................................
YES  NO  Heart surgery, a Pacemaker, etc? Details:..................................................................................................
YES  NO  Any other heart problems? Details:.............................................................................................................
.
NO 
NO 
NO 
NO 
NO 
NO 
YES 
NO  Epilepsy or fits? When was your last episode?...........................................................................................
YES 
YES 
NO  Stroke? When was the last one?..................................................................................................................
NO  Blackouts or giddy spells? How often?.....................................................................................................
YES 
YES 
NO  Bleeding or bruising problems? Details:...................................................................................................
NO  Blood Clots? Details:...................................................................................................................................
YES 
NO  Hepatitis, jaundice or liver problems? Details:..........................................................................................
YES 
NO  Kidney problems? Details:..........................................................................................................................
YES 
NO  Diabetes? What are your usual bold sugars & last HbA1c?.........................................................................
Do you use Insulin? YES  NO 
Do you use diabetic tablets? YES  NO 
YES 
YES 
NO  Rheumatoid Arthritis? Where?...................................................................................................................
NO  Do you have difficulty opening your mouth wide or limited neck movement?
YES 
YES 
NO  HIV, Hepatitis B or C, Golden Staph (MRSA) or VRE?.............................................................................
NO  Any other infectious diseases/s?...............................................................................................................
YES 
NO  Any medical conditions that run in the family (eg Thalassaemia)?..............................................................
YES 
NO  Frequent acid reflux or a large Hiatus Hernia?.............................................................................................
YES 
YES 
NO  Heartburn or reflux? How often? Daily  2nd Daily  Weekly  Less 
NO  A stomach ulcer or surgery on your stomach or oesophagus?..............................................................
YES 
NO  Frequent Headaches or Migraines? Details:.............................................................................................
YES 
NO  Glaucoma? What treatment do you take for it?............................................................................................
YES 
NO  Previous blood transfusion? When and where?........................................................................................
YES 
NO  Artificial joints or other implants? Details:..................................................................................................
YES 
NO  Are you (or could you be) pregnant? If so, how many weeks?....................................................................
YES 
YES 
NO  Have you had general anaesthetic before? When was the last one?..........................................................
NO  Have you had a spinal or epidural anaesthetic before? When was the last one?....................................
YES 
YES 
NO  Do you have any broken, loose, chipped or wobbly teeth? Details:..........................................................
NO  Do you have any caps, crowns, bridges, dentures or plates? Details:......................................................
Breathless or mild exertion?......................................................................................................................
Asthma or wheeziness? How often do you use a puffer?............................................................................
An admission to hospital for breathing problems?..................................................................................
Emphysema or frequent episodes of coughing or bronchitis?..................................................................
Sleep Apnoea or loud snoring? What treatment do you use?....................................................................
Tuberculosis now or in the past? When?....................................................................................................
BINDING MARGIN - NO WRITING
YES 
YES 
YES 
YES 
YES 
YES 