For 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
Parent/Guardian if 16 or under
Contact Address
Contact Details
Personal Details
Operation Details
Health Insurance Details
Hospital Cover

Do you have hospital cover?

Concession Details
Workcover or Third Party Details
Previous Anaesthetic Problems
Allergies and Sensitivities
Medication Details
Medical History

Have you had any operations in the past?

Have any of your relatives had probelms with anaesthesia?

Have you taken Aspirin, Warfarin, Clopogrel or other blood thinners in the last week?

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?

Pschiatric 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