Health Assessment Form

Health Assessment Form

Which hospital will you be attending?

Date of Procedure,if known

Name of Surgeon

Date of Birth

Could you be pregnant?

Next of Kin details

Next of Kin Telephone Numbers


Marital status



Language spoken at home

Interpreter required

Ethnic Origin

Country of Birth

Are you an Australian resident ?

Doctor Details

Referring Practitioner or GP Details

Date on your referral form/letter

Other Practitioner who you wish to receive correspondence

Medicare Details

*The Patient number is printed to the left of your name on the card

Funding Details

Please note, we are a private day hospital and where possible will be going through your health fund for your admission. We recommend you speak to your health fund prior to the procedure to confirm your policy covers you and to get an idea of the amounts payable as stipulated by your health fund

Discharge Planning

Do you live alone?

Do you have someone to look after you?

Name of the person collecting you from hospital

Phone number of the person collecting you from hospital

Relationship this person has to you

Anaethetic & Blood Clot / Bleeding Assessment

My partner has noticed that I stop breathing when asleep

My partner has noticed that I gasp when awake

Previous Anaesthetic problems?

Any Lung/Breathing condition?

Do you smoke?

I have noticed Reflux Acid up the back of my throat frequently

I have noticed Acid up the back of my throat when lying down

I have noticed Shortness of breath (SOB) or chest pain when walking

I cannot walk two flights of stairs without getting SOB or chest pain

Cardiac / Vascular

Cardiac conditions eg. Heart attack, congestive heart failure, rheumatic fever, valve disease, chest pain, angina

Cardiac irregularities eg. Palpitations, irregular hearbeat, heart murmur, atrial fibrillation

Cardiac surgery eg. Pacemaker, implants/devices, prosthetic heart valve grafts, stents, angioplasty, bypass or any other heart condition

Vascular disease eg. Carotid disease, arotic aneurysm, peripheral vascular disease

Are you on medication for High Blood Pressure? Please note: If the answer is yes please document the drug in the medication section


Kidney disease, dialysis, renal impairment

Do you have full control of your bladder/bowels?


Speech problems or swallowing problems eg. coughing when eating or drinking

Difficulties with attention span, understanding and/or problem solving

Epilepsy, fits, blackouts, funny turns

Short term memory loss or dementia

Stroke CVA/TIA's (transient ischeamic attacks)

Blood and Blood Clotting

Blood clot in lung/legs (DVT/PE)

Bleeding disorder? (eg: low platelets, anaemia)

Blood thinning medications? (eg: Wafarin, Coumadin, Plavix, Iscover, Asprin, Herbal Suppliments or Complimentary therapies (fish oil) and anti-inflammatory/steroid?)

Activities of Daily Living

Prosthetics / Aids / Other Visual Aids, Glasses, Content Lenses, Visual Impairment

Hearing aids, hearing appliance or hearing impairment, cochlear implant

Dentures, caps, crowns, loose teeth, implants, veneers

Other aides for daily living eg. Artificial limbs

Do you have an Advanced Health Directive? (If yes please bring with you to the hospital on the day of admission)



How is this controlled?

Infection Control

Do you have an infectious condition?

Hepatits B

Hepatits C

Hepatits HIV

Has someone in your family had Creutzfeldt Jacob Disease (CJD) also known as mad cow disease?

Have you received human pituitary hormones (growth hormones, gonadotrophins) prior to 1985?

Have you received a Dura mata "brain layer" graft between 1972-1989?

Have you received a Corneal transplant?

Do you have a current infection e.g. chest infection, skin cuts or abrasions?

Do you have a fever and/or repiratory symptoms (eg. cough, sore throat, runny nose)?

Do you have any other skin conditions or infections?

Have you ever had MRSA, VRE or ESBL?

Skin & Falls Assessment

Please indicate if any of the following apply


Have you experienced a fall in the last 6 months?

Do you have Multiple Sclerosis?

Do you have Peripheral Vascular disease?


Can cause an increased risk of falling post anaesthetic

Are you taking the following medication?



Anti Parkinson's drugs?

Diuretics (Fluid pills)?

Do you use Recreational drugs?

Have you received advice from your specialist rooms regarding taking/ceasing your medications prior to admission?

Do you currently take any chemotherapy medication?

Do you drink alchohol?


Please indicate if you require a special diet?

Surgical & Medical History

Do you have a family history of any of the following?

Bowel Cancer

Coeliac Disease

Breast Cancer

Crohns Disease

Liver Desease

Uterine Cancer

Bowel Desease


Ovarian Cancer

Ulcerative Colitis




Current Medications

By ticking the following boxes I acknowledge that I have read and understood the information contained within the following

Click Here to download the Patient Information Brochure


On the day of your admission, this form will be printed and you will be required to read and acknowledge the following as part of your admission.

I understand the importance of and agree to follow all instruction given to me relating to post-operative care

I undertake not to drive, operate machinery, drink alcohol, sign legal documents or make significant decisions following my anaesthetic, until the next day, or as advised by my doctor

I am aware I can discuss any queries I have with staff and doctors

I understand the hospital does not take any responsibility for the loss of any items I keep with me during my hospitalisation.

I have read and understood the information relating to my rights and responsibilities and agree to abide by my responsibilities in relation to my admission to the hospital

I have arranged for a responsible adult to collect me after my procedure/operation and to stay with me overnight

I agree NOT to take a taxi or public transport home when discharged and I understand that my surgery/procedure may be cancelled if I do not have a responsible adult to accompany me home

I Certify that the above information is accurate and that I have read and understood the information

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