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Patient Pre-Admission Form
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Home
About
Our People
Our Surgeons
Our Anaesthetists
Our Day Surgery Team
Our Reception Team
Specialties
Patient Information
Patient Pre-Admission Form
Contact
Patient Pre-Admission Form
Doctors Name
*
Operation Date
Date Format: MM slash DD slash YYYY
Arrival Time
:
HH
MM
AM
PM
Operation Time
:
HH
MM
AM
PM
Patient Details
Surname
Given Name/s
Address
Postcode
Postal Address
(If different from above)
Home Phone
Work Phone
Mobile
Email
Date of Birth
Date Format: MM slash DD slash YYYY
Australian Aboriginality
No
Yes
Sex
Male
Female
Country/State of Birth
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Occupation
Marital Status
Next of Kin/ Carer Details
Surname
Given Names
Address
Postcode
Relationship to Patient
Home Phone
Mobile
DESTINATION ADDRESS
(ie Home or other, please write)
Address
Health Insurance Information - Informed Financial Consent
**Bring Health Insurance Cards on Admission - Check with your Fund to ensure you have held membership for longer than 12 consecutive months**
Medicare No.
Ref No.
Name of Insurance Fund
Fund Membership No
DO YOU HAVE AN EXCESS ON YOUR POLICY?
Yes
No
(Please check with your Health Fund before admission)
EXCESS AMOUNT $
Excess will need to be paid to McCourt St Day Surgery on admission
UNINSURED DAY SURGERY FEE $
Fee will need to be paid to McCourt St Day Surgery on admission
Patient’s Signature
Click here
to create your own digital signature
Person or Party Responsible For Payment
(Do not complete if person is the patient)
Surname
Given Names
Address
Postcode
Relationship to Patient
Home Phone
Work Phone
Is Your Day Surgery The Result Of
Workers Compensation
No
Yes
Motor Vehicle Accident
No
Yes
Date of Accident
Date Format: MM slash DD slash YYYY
Insurance Details
Claim No.
Referring Doctor or Dentist
Name
Address
Confirm Rights & Responsibilities
Have You Read Your Rights And Responsibilities?
No
Yes
Do you understand them?
No
Yes
Hospital Questions
Have you been a patient at this hospital before?
No
Yes
Which year?
Previous name if different to this admission
Have you been hospitalised interstate or overseas in the last 12 months?
No
Yes
Where?
Pre-admission General Health Questionnaire
Patient / Guardian To Complete
Please tick box and specify where necessary.
Allergies (including Latex allergy)
Yes
No
Specify
Heart problems (chest pain, heart attack)
Yes
No
Specify
High or low blood pressure
Yes
No
Specify
Bleeding / clotting problems / bruise easily
Yes
No
Specify
Pacemaker / implanted defibrillater
Yes
No
Specify
Stroke
Yes
No
Specify
Fainting / blackouts / dizziness
Yes
No
Specify
Epilepsy / fits
Yes
No
Specify
Back or neck problems
Yes
No
Specify
Chronic / persistent pain
Yes
No
Specify
Breathing problems (shortness of breath, sleep apnoea)
Yes
No
Specify
Asthma or other respiratory disease / illness
Yes
No
Specify
Problems with an anaesthetic in the past
Yes
No
(including family members)
Specify
Do you smoke / Have you ever smoked?
Yes
No
(not just cigarettes)
Specify number per day or when ceased
Skin integrity (eg: tears / redness / infection)
Yes
No
Specify
Hepatitis / HIV Positive
Yes
No
Specify
Diabetes
Yes
No
Specify
Indigestion or reflux
Yes
No
Specify
Kidney disease
Yes
No
Specify
Dementia / episodes of delerium
Yes
No
Specify
Mental health issues (anxiety, depression)
Yes
No
Specify
Recent sore throat, cold or flu in the last 2 weeks
Yes
No
Specify
Previous recent surgery
Yes
No
Specify
Other history / other condition
Yes
No
Specify
Any possibility you are pregnant?
Yes
No
Specify
Have you had a fall in the last 6 months?
Yes
No
Specify
Do you use a walking aid?
Yes
No
Specify
Do you drink alcohol?
Yes
No
Specify daily intake
Do you have a documented Advanced Care Directive?
Yes
No
Specify
Please list
Weight
Height
Medications / Natural Medications
Please list your current medications and dosage
TYPE
DOSAGE
Have you ever taken or are you taking any of the following?
If yes, when did you stop taking
Aspirin
Yes
No
Date Ceased
Date Format: MM slash DD slash YYYY
Blood Thinners (eg; Warfarin)
Yes
No
Date Ceased
Date Format: MM slash DD slash YYYY
Steroid/Cortisone/Prednisolone
Yes
No
Date Ceased
Date Format: MM slash DD slash YYYY
Insulin
Yes
No
Date Ceased
Date Format: MM slash DD slash YYYY
Transport Questions
Have you arranged transport with a responsible adult and someone to stay with you for the next 24 hours?
Yes
No
N/A
Patient / Guardian Signature
Date
Date Format: MM slash DD slash YYYY