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Pre Admission Assessment

Pre Admission Assessment

Questions marked * are mandatory. Please attach your referral at the end of the assessment. If you don’t have it handy, just check with our staff to make sure your doctor has sent it through and we’ve received it.

PERSONAL INFORMATION

Title

Given Name *

Surname *

Date Of Birth *

Current Age

Admission Date *

Procedure Type *GastroscopyColonoscopyGastroscopy & Colonoscopy

Height (in CM) *

Weight (in KG) *

Sex *

Marital Status *SingleMarriedDefactoWidowedDivorcedSeparated

Home Phone

Work Phone

Mobile Phone

Email *

Street Address *

Suburb:

State:

Postcode:

Occupation *

Country Of Birth *

If Australia, which state

Resident *YesNo

Medicare Card Number

IRN

Expiry Date

Aboriginal and torres strait islander status *NoYes, AboriginalYes, Torres Strait IslanderYes, Both Aboriginal and Torres Strait IslanderDecline to answer

Interpreter requiredYesNo

Preferred Language

Have you been admitted to this hospital previously?YesNo

Year

Have you been admitted to any hospital within the past:7 Days?YesNo

Have you been admitted to any hospital within the past:28 Days?YesNo

If yes to either, please provide dates

If yes to either, please state previous hospital

Is this admission related:NoYes

Any related admissions prior to that?NoYes

If yes, please provide details:

Private Health Insurance Details Fund & Member no (if applicable, hospital cover only):

Ambulance Membership No (if applicable):

NEXT OF KIN DETAILS

NEXT OF KIN DETAILS

Name *

Phone *

Email

Relationship to patient: *SpousePartner/defactoSonDaughterOther (Please specify):

Other

PERSON COLLECTING YOU FOLLOWING PROCEDURE *YOU CANNOT LEAVE ON YOUR OWN IN A TAXI, UBER OR PUBLIC TRANSPORT

Name *

Phone *

Relationship to patient: *SpousePartner/defactoSonDaughterOther (Please specify):

Other

MEDICAL HISTORY

Please indicate if you have ever had any of the following conditions and provide relevant details where prompted.

Heart Attack *YesNo

Year: *

Angina or Chest Pain *YesNo

Heart Failure or Heart/Valve Disease *YesNo

Atrial Fibrillation, Palpitations or Other Irregular Heart Beat *YesNo

Specify: *

High Blood Pressure *YesNo

Low Blood Pressure *YesNo

Rheumatic Fever *YesNo

Cardiac Surgery: (e.g. pacemaker, internal defibrillator, prosthetic heart valves, grafts, stents, other implants/devices) *YesNo

Operation(s)/date(s): *

HAEMATOLOGY

Have you ever had a Blood Transfusion *YesNo

Describe any reaction: *

Year transfused: *

Blood clots in legs (DVT) Or Lungs (PE) *YesNo

Blood Disorders (e.g. anaemia) *YesNo

Tendency to bleed Or Bruise easily *YesNo

RESPIRATORY AND SLEEP DISORDERS

Asthma, Bronchitis, Emphysema, Chronic Obstructive Pulmonary Disease (Copd), Asbestosis, Pneumonia Or Shortness Of Breath *YesNo

Do you useNebulisersPuffersHome oxygen

Tuberculosis *YesNo

Sleep Apnoea *YesNo

Do you use CPAP machine: *YesNo

NEUROLOGY AND MENTAL HEALTH

Epilepsy or Fits *YesNo

Details

Anxiety, Depression, PTSD or other Mental Health Disorder *YesNo

Details

Parkinson’s, Multiple Sclerosis or Motor Neuron Disease *YesNo

Details

Stroke (CVA) or TIA *YesNo

Year: *

List any impairments: *

Dementia, Alzheimer’s *YesNo

Details

Difficulties with problem solving attention span or understanding *YesNo

Details

Experience Delirium Confusion or Aggression *YesNo

Details

RENAL

Kidney disease, Renal impairment *YesNo

On dialysis: *NoYes

Bladder problems (e.g. incontinence, retention) *YesNo

Details

MUSCULOSKELETAL, MOBILITY AND FALLS

Fainting, Dizziness Or Falls in the last 6 months *YesNo

Details

Do you require a mobility aid *YesNo

Mobility aid cond *WheelchairWalking frameStickOther (specify)

Other (specify)

Do you take four or more prescribed medications per day *YesNo

Details

Arthritis (e.g. osteoarthritis, rheumatoid arthritis) *YesNo

Details

Osteoporosis *YesNo

Details

Back or Neck injury or problems *YesNo

Details

Previous Back, Neck or Jaw Surgery *YesNo

Details

GASTROINTESTINAL

Reflux, Heartburn, Hiatus Hernia, Stomach Ulcers *YesNo

Bowel problems (e.g. Crohn’s, IBS, stoma, incontinence) *YesNo

Specify:

Liver disease, Jaundice, Hepatitis *YesNo

SKIN INTEGRITY

Pre-existing wounds or breaks in your skin *YesNo

Specify wound type and duration:

Eczema, Dermatitis *YesNo

ENDOCRINOLOGY

Thyroid Problems (e.g. goiter) *YesNo

Diabetes *YesNo

Diabetes radio *Type 1Type 2Gestational

How is it managed? *InsulinSGLT-2 inhibitorsDiet controlled

Other (specify):

ANAESTHETIC RISK AND OTHER CONDITIONS

Have you ever had an adverse reaction to Anaesthetics *YesNo

Type:

Has a close relative had an adverse reaction to Anaesthetics *YesNo

Have you ever had a difficult Intubation *YesNo

Do you have Dentures, Caps, Crowns, Loose Teeth, Implants Or Veneers *YesNo

Cancer conditions *YesNo

Type:

Any other condition we should be aware of *YesNo

Specify:

Have you had any previous operations or procedures *YesNo

Complete procedure and date performed below:

Procedure

Date Performed

GENERAL HEALTH AND LIFESTYLE

Have you ever Smoked *YesNo

If current smoker, daily amount:

If former smoker, year ceased:

Do you use Recreational Drugs *YesNo

Specify type and frequency:

Do you drink Alcohol *YesNo

Daily amount *

Have you unintentionally lost weight and/or had a decrease in Appetite recently *YesNo

Are you Pregnant or Breastfeeding *YesNo

If pregnant, number of weeks: *

Do you live alone *YesNo

Are you a carer for another person *YesNo

Do you currently receive community service *YesNo

Specify service: *

Do you require assistance with day to day living *YesNo

Specify assistance required: *

Do you have any cultural or religious needs *YesNo

Specify need(s):

PROSTHETICS AND AIDS

Visual aids or visual impairments (e.g. glasses, contact lenses) *YesNo

Hearing aids or hearing impairments (e.g. hearing aid, cochlear implant) *YesNo

Implanted devices *YesNo

Implanted Devices Checkboxes *Metal plates or pinsArtificial jointLap bandIntra-ocular lensPacemakerStentDefibrillatorOther (specify)

Other (specify):

ALLERGIES AND ADVERSE REACTIONS (ADR)

Do you have any allergies or adverse reactions to medication, tapes, latex, skin solutions or food *YesNo

Please enter details below

Allergy

Reaction

Date/year of reaction

BOWEL PREPARATION (For colonoscopy procedures only)

Have you suffered from constipation in the last 2 weeks *YesNo

Have you experienced an unexpected reaction to bowel preparation in the past *YesNo

Have you had difficulty clearing your bowels sufficiently in the past *YesNo

MEDICATIONS: PRESCRIPTION AND COMPLEMENTARY

Do you take any medications(e.g. blood thinners, diabetic medications), including all over-the-counter medications and vitamins(e.g. ginko, fish/grapeseed oil, St John’s wort) *If you are taking any blood thinning or arthritis medication (e.g. Warfarin, Plavix, Aspirin) please ensure you have advised your treating doctor and have received advice on whether you will need to stop any medication prior to admission.YesNo

Please enter details below or attach medication list:

Medication Name

Dose

Frequency

Taking for

INFECTION AND RISK SCREENING
IF YOU TEST POSITIVE FOR COVID IN THE 4 WEEKS PRIOR TO YOUR PROCEDURE PLEASE NOTIFY US.

Are you or anyone in your household currently experiencing any covid or covid like symptoms such as fever, chills, sweats, shortness of breath, sore throat, runny or stuffy nose, headache, muscle or body aches, loss or changes in smell and/or taste or nausea, vomiting or diarrhoea *YesNo

Have you had Covid *YesNo

If Yes, were you hospitalised?YesNo

What was the date that you tested positive?

Are you currently experiencing any type of infection or have you been exposed to a person that is suffering an infectious disease in the past 2 weeks e.G chicken pox, measles, influenza *YesNo

Have you ever been infected or colonised with a multi-resistant organism such as MRSA, VRE, CPE, ESBL, MRGN, Candida Auris? *YesNo

Do you have a blood born virus such as HIV, Hepatitis C or Hep B? *YesNo

Have you recently returned from travelling overseas(within the last 4-6 weeks) and/or have had an overnight stay at an overseas hospital or residential aged care facility in the past 12 months *YesNo

WHAT MATTERS TO YOU

Is there anything that matters to you, specifically regarding your hospital stay that we need to know?NoYes

specify: *

Do you understand your healthcare rights (https://directendoscopy.com.au/your-privacy/) *NoYes

LEGAL DOCUMENTATION

Note: Please attach or bring a copy of any relevant documentation

An Advance Care Directive is a set of written instruction that a person gives that specifies what actions should be taken for their health if they are no longer able to make decisions because of illness or capacity

Do you have a current Advance Care Directive? *Please attached of bring a copy of you would like it included with your medical record, or note below where a copy may be obtained if required.YesNo

Name (please print):

Contact number:

Enduring Power of Attorney or legally appointed medical treatment decision-maker

Do you have an Enduring Power of Attorney or legally appointed medical treatment decision-maker?YesNo

Name

Relationship to patient

Contact number

Details

DISCHARGE PLANNING

You must not engage in the following activities for 24 hours following your operation/procedure or as directed by your doctor:

Drive a motor vehicle, ride a bicycle or operate machinery of potentially dangerous appliances;
Make any important decisions or sign legal documents;
Drink alcoholic beverages or take recreational drugs.

You must arrange and advise the hospital of a responsible adult to drive you home and stay with you overnight. As this is important for your safety after receiving anaesthetic, failure to do this may result in your procedure being cancelled or postponed.

PROCEDURE SAFETY AND RISKS

Gastroscopy is considered very safe, with serious complications extremely rare, these include bleeding and reaction to sedation or perforation.

Colonoscopy procedures are generally safe, but complications can occur. These include headache, nausea from bowel prep solutions, uncommon risks of bleeding after biopsy and polyp removal and perforation and damage to the spleen.

Due to the risk of cancer, we aim to remove all polyps at the time of the procedure. If you have any reservations or queries about this, please discuss and inform your doctor.

In the unlikely event, you may experience a significant blood loss (bleed) after your procedure. You will require a blood transfusion.

I have read, understood and consent to the above safety and risks.

HEALTHCARE RIGHTS

A copy of your healthcare rights can be found on our website https://directendoscopy.com.au/your-privacy/ Or onsite at any facility in the reception area.

PATIENT AGREEMENT

I certify that the information provided is true and accurate to the best of my knowledge and I have read and understood the discharge planning requirements as above.

Patient name

Upload ReferralPLEASE ENSURE YOU ALSO BRING THE ORIGINAL COPY OF YOUR REFERRAL ON THE DAY OF YOUR PROCEDURE

No file chosen

Date

We participate in the My Health Record system. This allows for secure sharing of your health information with other authorized healthcare providers. Your participation is voluntary. Would you like to have your health information uploaded to your My Health Record?NoYes

A Centaurus Healthcare company, offering expert gastroenterology, endoscopy, and digestive care across our network.

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Patient Info
Careers
- For Anaesthetists & VMOs
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Contact
Book Online
Pre Admission Assessment

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