Pre-operative assessment | Manchester Private Hospital

About you

Your appointment

Full name

Likes to be known as

Date of birth

Proposed procedure

Consultant

Local / general anaesthetic / sedation

Height and weight

Height (cm)

Weight (kg)

BMI

Your BMI is worked out for you.

Next of kin

The person we should contact

Relationship to you

Title

Full name

Phone number

Email

Address

Town or city

Postcode

Your GP

Your GP practice

GP practice name

GP (doctor) name

Practice address

Town or city

Postcode

Practice phone number

Practice email

Other care and allergies

Are you under the care of any other healthcare professional? (for example a specialist doctor or psychiatrist)

Yes No

Who is caring for you, and how long have you been under their care?

Do you have any allergies or sensitivities? (rubber/latex, medicines, foods, metal substances)

Yes No

What are you allergic to, and what reaction do you have?

Medicines

Are you a diabetic?

Yes No

Type of diabetes

When was your last HbA1c blood test?

What was the HbA1c result?

Insulin

Tablets

Diet

Are you currently taking anticoagulants/blood thinners?

Yes No

Details

Are you currently taking any anti-inflammatory medicines? Eg ibuprofen, naproxen, meloxicam or diclofenac

Yes No

Details

Any anti-inflammatory medicines (for example ibuprofen or diclofenac) should be stopped 2 weeks before your surgery, unless your surgeon tells you otherwise.

Are you taking any steroids? E.g. prednisolone

Yes No

Details

Are you currently using any inhalers?

Yes No

Details

List of current medication (including over the counter, herbal medication and supplements)

Recent infections and illness

Lifestyle

Do you smoke or have you ever smoked?

Yes No

When?

Do you drink alcohol? If so, how many units per week?

Yes No

Details

Do you use any recreational substances?

Yes No

Details

Do you have any special dietary requirements?

Yes No

Details

Are there any cultural/religious beliefs or values we should be aware of?

Yes No

Details

Do you have any disabilities?

Yes No

Details

Cancer

Have you ever been diagnosed with cancer?

Yes No

When?

Are you under the care of an oncologist?

Yes No

Details

Heart and circulation

Breathing and lungs

Kidneys and bladder

Hormones and glands

Blood

Brain and nerves

Muscles and joints

Stomach and bowel

Covid-19

Have you ever tested positive for Covid-19?

Yes No

When?

In the last 14 days, have you or anyone in your household been unwell with any of the following?

Tested positive for Covid-19

Yes No

Details

A high temperature or shivering (chills) – a high temperature means you feel hot to the touch on your chest or back

Yes No

Details

A new continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours

Yes No

Details

A loss or change to your sense of smell or taste

Yes No

Details

Shortness of breath

Yes No

Details

Feeling tired or exhausted

Yes No

Details

An aching body

Yes No

Details

A headache or sore throat

Yes No

Details

A blocked or runny nose

Yes No

Details

Loss of appetite

Yes No

Details

Feeling or being sick or suffering from diarrhoea

Yes No

Details

Had a temperature greater than 37.8 degrees

Yes No

Felt unwell

Yes No

Result of Covid-19 Test 48 hours prior to admission

Positive Negative N/A

Details

Result of Covid-19 Test on admission

Positive Negative N/A

Details

Anaesthesia

Have you or any of your blood relatives had a problem with any anaesthetic?

Yes No

Details

Have you ever been admitted to an intensive care unit?

Yes No

Details

Do you have any fears or anxieties about your anaesthetic?

Yes No

Details

Is there any possibility you may be pregnant?

Yes No N/A

Date of your last menstrual period

Any other comments

Going home

Will you be discharged to your home address?

Yes No

Details

Do you have someone to take you home?

Yes No

Details

Are you able to be taken home by car?

Yes No

Details

Is there a responsible adult available at home for the first 24 hours?

Yes No

Details

Check your answers

Tap a section to change it. When everything is right, press Send my answers.

I confirm the information I have given is correct to the best of my knowledge.