GME THEATRE ADMISSION FORM (May-21)

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

PATIENT ADMISSION DETAILS

Mornington Endoscopy (350 Main Street, Mornington) (03) 5973 4444Rosebud Endoscopy (20 Boneo Road, Rosebud) (03) 5986 4444

PATIENT DETAILS

Please document as your name appears on your Medicare Card

Street Address

Street Address Line 2

SuburbState

Post Code

Please enter a valid phone number.

MaleFemalePrefer not to disclose

YesNoDecline to answer

Yes, AboriginalYes, both Aboriginal & Torres Strait IslanderYes, Torres Strait Islander

FINANCIAL DETAILS

Surname:Given Name:Relationship:

Please enter a valid phone number.

Surname:Given Name:Relationship:

Please enter a valid phone number.

PATIENT PRE-ADMISSION HISTORY

Yes, please bring on admissionNo

YOUR PHYSICAL HEALTH & MEDICAL HISTORY

	YES	NO
Heart Attack
Heart Failure
Angina
Cardiomyopathy
Heart Stents
Heart Bypass Surgery
Artificial Heart Valve
Cardiac Implant
Defibrillator
Pacemaker
Irregular Heart Beat
Heart Murmur
High Blood Pressure
Low Blood Pressure
Stroke (CVA)
Deep Vein Thrombosis (DVT)
Pulmonary Embolism (PE)
Vascular Disease
Aneurysm
Neuromuscular Disease
Parkinson's
Multiple Sclerosis (MS)
Epilepsy
Seizures
Severe Kidney Disease
Impaired Kidney/Renal Function
Dialysis
Removal of Kidney
Liver Disease
Hepatitis
Jaundice
Gastro Oesophageal Reflux (GORD)
Bleeding Disorder
Rectal Bleeding
Anemia
Stomach Ulcer
Lymphoedema
Depression
Mental Illness
Anxiety
Panic Attacks

HEALTH & RISK ASSESSMENT

DietInsulinTabletsOther

FaintingNausea & VomitingHeadachesOther

Advanced Care DirectiveAdvanced Care PlanEnduring Power Attorney

INFECTION CONTROL RISK ASSESSMENT

	YES	NO
Are you suffering from any pre-existing health care associated infection or communicable disease?
Have you been in contact with anyone in the last month suffering from a severe infectious disease?
Have you been diagnosed with an infection cause by a multi-resistant organism? e.g. golden staff, MRSA
Have you been admitted to any overseas hospital or aged care facility in the last 12 months?
In the last 14 days have you suffered from ANY respiratory illness symptoms? e.g. temperature, cough, sore throat, body aches, body shaking (rigors), breathing difficulties, fatigue, loss of taste or smell?
Have you been diagnosed with COVID-19/Coronavirus in the last 4 weeks?
Have you had contact with a person diagnosed with COVID-19 in the last 4 weeks?
Have you returned from an area that has a high prevalence of COVID-19 in the last 4 weeks?

SURGICAL HISTORY

ANAESTHETIC HISTORY

	Yes	No
Nurse Admission Completed
Medical History Checked
Observations Documented
Preparation taken as instructed
Has the patient been offered Rights & Responsibilities Information
Does the patient have suitable escort arrangements

Click submit to record your responses.

GME Theatre Admission Form