Pre-Anaesthetic Questionnaire (Demo)

Pre-Anaesthetic Questionnaire (Demo)

Dr. Stuart Watson
Anaesthetist's details
VPAC ID
Anaesthetist's Full Name and Title
VPAC Email
Opening Message
Addressee
Dear Patient,

Thank you for taking the time to complete this form. It helps me to:
- Tailor your anaesthetic, thereby improving safety and comfort
- Request information ahead of time, so as to avoid delay or cancellation
- Spend more of our consultation discussing matters important to you
Sincerely,

Dr. Stuart Watson

End User Terms
Before we begin:

I understand that by using Virtual PAC, I agree to the End User Terms
You can learn more about how your information is handled in our Privacy Policy and Privacy Collection Statement.
Formatting
Hidden Yes multi-choice

Yes
Hidden No multi-choice

No
Hidden ? multi-choice

?
Impossible
Notifications
Red flag Sx (notifications):
Functional status x Green Flag:
Red flag Hx (notification):
Red flag Rx (notification):
Phone call? (notification)
Questions? (notification)
*ALERT*

YesNo

Patient's Details
Name

First NameLast Name
Date of Birth:

DayMonthYear
Date
Today's Date (picker)

DayMonthYear
Date
Age - years
Age (number format)
Age - extra months
Age:
(Auto-filled)
Sex
Are you pregnant or breastfeeding?
O&G Alert

PregnantBreastfeeding
Height (cm)
Weight (kg)
BMI (calc)
BMI (number format)
Height & Weight
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Are you filling out this form for yourself?
Filling out own form?

YesNo

Emergency Contact

e.g. parent, child, spouse
Contact's Name:

Contact's First NameContact's Last Name
Relationship to patient:
Contact's Phone Number:
Please enter a valid phone number.

Doctors' Details
Do you have a regular General Practitioner?
General Practitioner:

No
General Practitioner:
Do you see any Specialists?
Specialists:

No
Specialists:
May I request your medical information from other healthcare providers?
Permission to request medical info:

YesNo

Operation Details
Are you having any of the following day procedures?

Gastroscopy or colonoscopyNerve block or ablationSkin lump removal or biopsyFinger or toe surgeryEye surgery*NONE OF THE ABOVE*
Green Flag Operation:
What operation are you having?
Operation:
Who is your surgeon/proceduralist?
Proceduralist:
When is your operation?

DayMonthYear
Date
Date:

DayMonthYear
Date
Where is your operation?
Name of hospital
Location:
Why are you having this operation?
Indication:
Start:

MonthDayYear
Date
Finish:

MonthDayYear
Date

Past Medical History:

Other
Have you had any medical problems not listed above?
Please provide details:
Other Medical Hx:

No
Other Medical Hx:

Attachments
Are there any documents you would like to share with your anaesthetist?
Attachments

No
File 1

Cancelof
File 2

Cancelof
File 3

Cancelof
File 4

Cancelof
File 5

Cancelof

Final questions
Would you like your anaesthetist to call you prior to the procedure?
Request for pre-op phone call:

YesNoDon't mind
Do you have any specific questions, concerns or requests?
Please provide details:
Special requests:

No
Special requests:
*DISCLAIMER*

Regarding use of this questionnaire
Should be Empty: