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Pre-assessment form

We are delighted that you have chosen Phoenix Hospital Group for your operation.

We would be grateful if you would spend a few minutes completing this questionnaire as soon as possible. This will then be reviewed by our Pre-assessment Nurse. It is important you follow our recommendations on isolating between now and your admission.

We recommend you to isolate for seven days prior to your procedure with the exception of having your Covid swab taken.

Failure to complete this questionnaire may result in your procedure being cancelled one the day. The Pre-assessment Nurse will liaise with your consultant anaesthetist to decide whether any further tests or investigations are needed, and to ensure your anaesthetic is the safest possible.

If you have any questions, please contact the Pre-assessment Nurse on:

0203 075 2338 (Weymouth Street Hospital)

01245 801234 (Phoenix Hospital Chelmsford)

 

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    COVID 19 Information

    The following questions are designed to keep the hospital, patients and staff as free as possible from COVID-19. It is essential you answer them as truthfully as possible. We will be happy to discuss your concerns. If you have any of the following symptoms prior to your admission please contact our Pre-assessment team to discuss the best way to proceed; new continuous cough, high temperature, shortness of breath or loss or taste and smell.

    Vaccination status*
    Have you ever tested POSITIVE for COVID-19?* (Lateral flow or PCR)

    Do you have any ongoing symptoms or complications from your COVID-19 infection? (Cough, shortness of breathe, fatigue)

    Have you travelled outside the UK in the 7 days prior to admission to our hospital?

    Patient Details













    About You

    Do you smoke cigarettes or vape?
    Do you drink alcohol?

    Do you take recreational drugs?
    Do you have vision or hearing impairment? (Do you wear glasses or hearing aids?)

    Have you had any dental work performed in the last 6 months?

    Any body piercings?
    Any loose teeth, crowns or plates?


    Surgical History

    Have you ever been to Weymouth Street Hospital or Phoenix Hospital Chelmsford before?
    Have you ever had an operation?*

    Have you ever had a general anaesthetic? (i.e this is where you have been unconscious)*

    Have you or a relative ever had a problem with an anaesthetic?

    Asthma

    Have you ever suffered from asthma? *
    Please tick all that apply:

    Respiratory

    Do you have any lung problems? (Include chronic diseases and shortness of breath) *
    Please tick all that apply:

    Obstructive Sleep Apnoea

    Do you snore*
    Have you been diagnosed with Obstructive Sleep Apnoea?*
    Do you snore loudly?
    What is your collar size? (inches)
    Do you feel tired, fatigued or sleepy during the day?
    Has anyone observed you to stop breathing during your sleep? (Partners often report the person snores, then is silent for a few seconds)
    Please provide as much information as possible.
    Cardiovascular

    Have you ever had heart disease, high blood pressure, chest pain or heart palpitaions?*
    Please tick all that apply:
    Do you have any of the following?
    Please provide as much information as possible.
    The dates and results of any investigations would be helpful (dd/mm/yyyy)
    Renal

    Have you ever had kidney, urinary or prostate problems?* (Women can exclude up to 3 urinary tract infections)
    Please tick all that apply:
    If you are male, do you have prostate problems. Frequency, poor stream, difficulty passing urine, getting up at night to urinate?
    Please tick if you have you had:
    Please provide as much information as possible.
    Hepatic

    Have you ever had liver disease?*
    Please tick all that apply:
    Please provide as much information as possible.
    Pancreas

    Have you ever had pancreatitis?* (Please include cysts and pancreatic cancer)
    Gastrointestinal

    Have you ever had indigestion or stomach problems?* (This includes reflux, heartburn & ulcers)
    Please tick all that apply:
    Please provide as much information as possible.
    Diabetes

    Have you ever had diabetes?* (Please include diabetes in pregnancy)
    Please tick all that apply:
    Please provide as much information as possible. If you are on insulin, this will need to be modified before your operation and the Pre-assessment nurse will contact you
    Neck problems

    Have you ever had neck problems?* (Please include trauma, ankylosing spondylitis and an increasingly stiff neck)
    Please tick all that apply:
    Please provide as much information as possible. If you are on insulin, this will need to be modified before your operation and the Pre-assessment nurse will contact you
    Clotting

    Have you had bleeding problems or clots?* (This includes DVT, pulmonary embolus, Factor V Leiden and Haemophilia)
    Please tick all that apply:
    Please provide as much information as possible.
    Haematology

    Have you had anaemia, blood problems or leukaemia?* (Please include sickle cell, thalassaemia and other inherited problems)
    Please tick all that apply:
    Please provide as much information as possible. If you have a recent haemoglobin test result please provide the result
    Neurology

    Have you ever had fits, a stroke, TIA (mini stroke), brain tumour, blackouts/fainting or receive treatment from a Neurologist?*
    Please tick all that apply:
    Please give further details.
    Mental Health and Memory Loss

    Have you ever had bipolar disease (depression), schizophrenia, claustrophobia or memory loss?*
    Please tick all that apply:
    Please provide further details if possible.
    Thyroid

    Have you an under or over active thyroid? *
    Please tick all that apply:
    Please provide as much information as possible. IF YOU ARE ON THYROXINE PLEASE ASK YOUR GP FOR YOUR LATEST BLOOD TEST AND BRING IT INTO HOSPITAL
    Medication and Drugs

    Are you taking any medication? Have you taken steroids in the last three months? Please include over the counter and recreational drugs , vitamins and Chinese herbs *
    Please list all the drugs you are taking. The dosage would be helpful, especially if you are on insulin
    Allergies

    Are you allergic to any drugs, medicines, foods or LATEX?* (Include anything that causes a rash, wheezing, difficulty breathing or anaphylactic shock)
    If yes, please provide details. Please state the name of the drug or allergen and what reaction you had. Your GP may be able to assist you if you cannot remember.

    Infections

    Please tick if you have or have had any of the following infections
    Please tick if any of the below apply to you
    Please state the hospital or country
    Please provide as much information as possible.
    Mobility

    Have you had falls?*
    Can you lay flat?
    Do you have mobility problems or need mobility aids? *
    Please provide as much information as possible.

    Needle Phobia

    Do you have a needle phobia?*
    Additional Details

    Are you under any specialists doctors or your GP for current investigations?*
    If you answered yes to the above, please specify.
    Will you be on your period during your hospital admission?*
    Are you currently breastfeeding?*
    If there is anything else that is not covered in the questions above, which you feel we should know, please give further details below:
    Statement

    Please type your name and press the submit button. The questionnaire will go to our Pre-assessment nurse who will coordinate with your consultant anaesthetist. We will contact you if we need any further information or require any further tests.

    Thank you for your help and we hope you have a comfortable stay at Phoenix Hospital Group.

    Type your name below to accept*



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