• GME Theatre Admission Form

    GME Theatre Admission Form

  • Form must be returned at least 10 business days prior to admission.

  • PATIENT ADMISSION DETAILS

  • LOCATION*
  • Date of Procedure:*
     - -

  • PATIENT DETAILS

    Please document as your name appears on your Medicare Card

  • Format: 0000-000-000.
  • Sex/Gender:
  • Date of Birth*
     - -
  • Are you an Australian Resident?*
  • Are you of Aboriginal or Torres Strait Islander origin?
  • If yes,

  • FINANCIAL DETAILS

  • Expiry Date:
     - -
  • Expiry Date:
     - -
  • Do you have Ambulance Cover with Ambulance Victoria?
  • Do you have Ambulance Cover through your health fund? (Please note not all ambulance costs are 100% covered under health insurance)
  • Format: 0000-000-000.
  • Format: 0000-000-000.
  • Format: 0000-000-000.

  • OFFICE USE ONLY

  • PATIENT PRE-ADMISSION HISTORY

  • Do you have x-rays, blood tests or ultrasounds relevant to your admission?
  • Have you been hospitalised anywhere in the last seven days?

  • YOUR PHYSICAL HEALTH & MEDICAL HISTORY

  • Rows
  • Do you have any other illnesses or conditions you would like us to be aware of?*

  • HEALTH & RISK ASSESSMENT

  • Rows
  • Do you have Sleep Apnoea?*
  • Do you have CPAP machine?
  • Do you have Diabetes?*
  • If yes,
  • If you have diabetes is it managed with:
  • Do you take blood thinning medication?*
  • If yes, please check
  • Are you or could you be Pregnant?*
  • Are you currently breastfeeding?*
  • Have you fainted in the last three months?*
  • If you have had a colonoscopy previously have you had any problems when taking the bowel preparation?*
  • If yes,
  • Have you had a fall in the last 6 months?*
  • Do you live alone?*
  • Do you have any mobility aids? e.g walking stick, frame, wheel chair?*
  • Do you have an Advanced Care Directive, Advanced Care Plan or Enduring Power Attorney? (If yes, please bring copy into GME)*
  • If yes,
  • Do you have short term memory loss, cognitive impairment or dementia?*
  • Have you ever experienced any episodes of delirium?*
  • Do you have any other special needs you would like us to be aware of?*

  • INFECTION CONTROL RISK ASSESSMENT

  • Rows

  • SURGICAL HISTORY

  • Have you ever had a previous surgery?*

  • ANAESTHETIC HISTORY

  • Have you ever had any previous anaesthetics or sedation?*
  • Have you or any member of your family had problems with anaesthetics or sedation? (Please specify)*
  • Do you smoke?*
  • Do you consume alcohol?*
  • Do you take sedatives or sleeping medications?*

  • MEDICATIONS

  • Are you taking any medications at present?*

  • PATIENT DECLARATION

  • I certify that I have a responsible adult who will accompany me home after my procedure and stay with me overnight. I understand that my procedure may be cancelled if these arrangements are not confirmed and in place prior to my admission for my procedure. I understand the importance and agree to follow instructions regarding my 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 advised by my doctor.

  • OFFICE USE ONLY

  • Rows
  • Rows
  • Rows
  • Date
     - -

  • Click submit to record your responses.

  • Should be Empty: