Royal Perth Hospital - Preadmission health assessment questionnaire

What is your primary spoken language? English Other

Please specify your primary spoken language

Do you require an interpreter? No Yes

What is your height (cm)?

What is your weight (kg)?

Have you been hospitalised outside WA in last 12 months? No Yes

Medical History

Do you have a history of:

Heart attack / chest pain / angina / heart disease? No Yes

Date Please describe

Irregular heartbeat? Heart murmur? No Yes

Please describe

High blood pressure? No Yes Stroke, TIA’s or blackouts? No Yes

Ongoing impairment? No Yes

Do you currently have a blood clot? No Yes

Date of clot:

Bleeding disorders / recurrent blood transfusions / peripheral vascular disease? No Yes

Please describe

Diabetes? No Yes

Do you require insulin? No Yes

Sleep apnoea / heavy snoring/ choking or gasping in your sleep? No Yes

Treated with CPAP? No Yes

Do you need to use more than one pillow to assist breathing when you sleep? No Yes Lung disease e.g. chronic bronchitis, emphysema or asthma? No Yes

Any hospitalisation for your breathing in the last 2 years? No Yes

Please describe

Lung surgery? No Yes Infections e.g. TB, Hep B or C, MRSA, VRE, HIV? No Yes Epilepsy or fits? No Yes

Have you had a seizure within the last 12 months No Yes Date of last seizure:

Diagnosed mental health condition e.g. bipolar affective disorder, schizophrenia? No Yes

Have you required hospitalisation within the last 2 years? No Yes

Kidney disease or bladder problems? No Yes

Are you on dialysis? No Yes

Liver disease? No Yes Muscle disease or progressive weakness? No Yes

Please describe

Neck / back / joint problems? No Yes

Please describe

Short term memory loss or dementia? No Yes

Please describe

Reflux / indigestion / hiatus hernia? No Yes Cancer of any type? No Yes

Please specify the type of diagnosis Please specify the date of diagnosis

Are you, or is there a possibility you may be pregnant? No Yes

How many months?

Are you breastfeeding? No Yes Do you have any other health conditions not mentioned? No Yes

Please describe

Current Medications

Do you take any medications - Including natural, herbal and recreational drugs, inhalers and insulin? No Yes

Please list ALL medication you are currently taking including puffers, patches, injections, contraceptive pill, creams, eye/ear medications, over the counter non prescribed medication (e.g. herbal/naturopathic/vitamins and complementary)

Name of Medication	How much? (Dose)	How often each day? (Frequency)

Name of regular pharmacy (including suburb)? Does your pharmacy pack your medications? No Yes

Allergies

Have you ever had a reaction/allergic reaction to a medication? No Yes

Which medication?

Have you ever had a reaction to iodine/chlorexidine? No Yes Do you have a latex allergy? No Yes

Surgical and Anaesthetics

Do you have any medical implants? e.g. pacemaker / deﬁbrillator / valves / stents No Yes

Please describe

Have you ever been told you have a ‘difﬁcult airway’ or there was difﬁculty with placement of a breathing tube while you were anaesthetised? No Yes Would you object to having a blood transfusion if needed? No Yes Have you or anyone in your immediate family had a serious anaesthetic reaction? e.g. malignant hyperthermia No Yes

Please describe

Surgical History

Please list any operations you have had below

Have you had any previous surgeries? No Yes

List past surgeries, year of surgery, any long-term issues associated with the surgery.

Operation	Date	Location (i.e. Hospital)

Admission and Discharge Needs

Will you have access to transport home and overnight care? No Yes Do you live alone? No Yes Do you live in a hostel, nursing home or supported accommodation? No Yes Are you the primary carer for someone? No Yes

Please describe

Do you require physical assistance or use a walking aid to walk? No Yes

Please describe

Do you need help with self-care? e.g. bathing, dressing No Yes

Please describe

Do you receive support services? e.g. home help, NDIS, ACAT, Silver Chain etc. No Yes

Please describe

Acknowledgement

Patient Declaration

Royal Perth Bentley Group is committed to safeguarding the privacy of patient information. We take all reasonable steps to safeguard your information which is held in either paper or electronic files by storing them securely.

It may be necessary for us to obtain copies of reports such as x-ray’s, pathology results and correspondence from other medical practitioners, healthcare professionals or your general practitioner regarding your medical treatment.

If you do not wish for us to collect and release information about you, you need to tell us and we will discuss with you the impact this may have for your health care. Please call RPH 6477 5139 / BHS 9416 3824.

Royal Perth Bentley Group conducts a wide variety of research projects that aim to guide best practice in surgical patients. Individuals that are eligible for specific projects will be routinely approached by research staff to discuss whether they wish to participate.

Useful websites for more information:
HealthyWA - Going to hospital
WA Health YouTube

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Pre-Admission Health Assessment Questionnaire

Instructions

What happens next ?

Medical History

Do you have a history of:

Medications

Current Medications

Allergies

Surgical and Anaesthetics

Surgical History

Please list any operations you have had below

Admission and Discharge Needs

Acknowledgement

Patient Declaration