Patients

Health Questionnaire

Simply download the SAS Health Questionnaire, fill in the details and return to us at:

Specialist Anaesthetic Services
PO Box 573
Unley SA, 5061

Fax: (08) 8274 1993

Alternatively, you can submit the health questionnaire online by completing the following form:

Patient Details
Name

PARENT/GUARDIAN IF 16 OR UNDER

parent/guardian

CONTACT ADDRESS


Address

Contact Details


Personal Details

Operation Details
Health Insurance Details

Hospital cover

Do you have hospital cover?

CONCESSION DETAILS

Concession
Workcover or Third Party Details
Address
Previous Anaesthetic Problems
Allergies and Sensitivities
Medication Details
Past Operations
Have you had any operations in the past?
Past Operations
Medical History
Have any of your relatives had problems with anaesthesia?
Have you taken Aspirin, Warfarin, Clopidogrel or other blood thinners in the last week?
Have you received a Therapeutic Good Administration (TGA) approved Covid-19 vaccine?

DO YOU HAVE OR HAVE YOU EVER SUFFERED FROM...

Heart Problems?

eg. Palpitations, fainting, heart murmurs

High blood pressure?
Breathing or respiratory difficulties?
Obstructive sleep apnoea?
Diabetes?
Kidney disease?
Neck or jaw stiffness?
A Gastric Band or Bypass Surgery
Epilepsy, seizures or convulsions?
Psychiatric illness?
Contact with infectious disease?

eg. Hepatitis, HIV or AIDS

Previous blood clots or pulmonary embolism?
Unusual or excessive bleeding or bruising?
Heartburn, gastric reflux or hiatus hernia?
Dental Problems?
Do you Smoke?
Do you drink alcohol?
Females - is there any possibility you are pregnant?
Extra Information