Esph Patient History Form Page 2
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3PREVIOUS OPERATIONS / PROCEDURES / ANAESTHETIC DETAILS
Have you had previous operations, please list dates and operations performed:
Date
/
/
Date
/
/
Date
/
/
Date
/
/
Date
/
/
Date
/
/
NO
YES SPECIFY DETAILS
Have you or anyone in your immediate family ever
Details of reaction
had a reaction to an anaesthetic? eg. malignant hyperthermia
Have you ever had a blood transfusion?
Details of any reaction
PROSTHESIS / AIDS / OTHERS
Glasses/Contact Lenses
Hearing aid or other hearing appliance
Body Piercing
Dentures/Caps/Crowns/Loose Teeth
Artificial joints or limbs
Metal plates/pins
LIFESTYLE
Have you ever smoked?
Daily amount
or date ceased
/
/
Do you drink alcohol?
Daily amount
Do you use recreational drugs?
Type Daily amount
Do you require a special diet?
Type of Diet
Do you exercise?
< 30mins per day
30mins per day
30mins per day plus aerobic activity 3 times per week
Do you require an interpreter?
Language spoken at home
Do you have someone to interpret for you?
Name of Person
Have you a fear of falling or have fallen within the last 6 months?
Do you use mobility aids
Yes
No
Have you experienced fainting or dizziness in the last 6 months?
ALLERGIES
Do you have any allergies to medications, food, sticky plaster,
Specify Details and Reaction:
latex/rubber (e.g. balloons, gloves) or other substances?
INFECTION RISK
Have you travelled to a country with a health alert in the
last 7 days
Do you have a fever and/or respiratory symptoms eg. cough,
sore throat, runny nose
Have you had recent contact with patient/s diagnosed with
Acute Respiratory Infections or Acute Respiratory Ilness in the
last 7 days (Seasonal of Pandemic) eg. SARs/H5N1 Influenza,
either overseas or in Australia, within 7 days of onset of
symptoms
Have you travelled to areas of high prevalence for Acute
Respiratory Infections or Acute Respiratory Ilness in the last 7
days (Seasonal of Pandemic) eg. SARs/H5N1 Influenza, either
overseas or in Australia, within 7 days of onset of symptoms
Have you ever had MRSA, VRE or ESBL
Do you have any wounds or breaks on your skin
Do you have any other conditions or infections
Have you had vomiting and diarrhoea in the past 48 hours
QUESTIONS RELATING TO
CREUTZFELDT JAKOB DISEASE
Have you had a dura mater graft between 1972 - 1989?
Do you have a family history of 2 or more relatives with CJD or
other unspecific progressive neurological disorder?
Have you received human pituitary hormones (growth
hormones, gonadotrophins) prior to 1985?
Has the patient suffered from a recent progressive dementia
(physical or mental), the cause of which has not been diagnosed?
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