Pre Admission Assessment | Direct Endoscopy

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Questions marked * are mandatory

PERSONAL INFORMATION

TITLE *

FIRST NAME *

SURNAME *

PREVIOUS SURNAME

DATE OF BIRTH *

DATE OF ADMISSION *

PROCEDURE NAME *

CONTACT NUMBER *

ALTERNATE CONTACT NUMBER

OFFICE USE

ANAESTHETIST NAME:

SIGNATURE:

DATE:

PATIENT APPROVED FOR PROCEDURE:

YES NO

BMI:

VARIANCE IN ADMISSION (EG PAC Required, change of Medications etc):

Bowel Prep Suggested:

3 Picosalax 4 Picosalax

Alternate Bowel Prep Solution:

Referral for review by a Gastroenterologist

ADDRESS *

COUNTRY OF BIRTH *

IF AUSTRALIA, WHICH STATE

RESIDENT *

Yes No

HEIGHT (in CM) *

WEIGHT (in KG) *

GENDER *

MARITAL STATUS *

OCCUPATION *

ABORIGINAL AND TORRES STRAIT ISLANDER STATUS *

INTERPRETER REQUIRED (Available at a cost to the patient)

Yes No

PREFERRED LANGUAGE

MEDICARE NUMBER AND REFERENCE NUMBER *

(numbers only- no spaces or dashes between numbers)

MEDICARE EXPIRY DATE *

AMBULANCE SUBSCRIPTION NUMBER, if applicable

PRIVATE HEALTH INSURANCE FUND AND NUMBER (HOSPITAL COVER ONLY) DVA GOLD NUMBER

HAVE YOU BEEN ADMITTED TO THIS HOSPITAL PREVIOUSLY? If yes, what year?

HAVE YOU BEEN ADMITTED TO ANY HOSPITAL WITHIN THE PAST:

7 DAYS?

Yes No

28 DAYS?

Yes No

If yes to either please state previous hospital and reason for the admission?

Emergency Details

NEXT OF KIN NAME *

NEXT OF KIN CONTACT NUMBER *

NEXT OF KIN ADDRESS *

RELATIONSHIP TO NEXT OF KIN *

NAME OF THE PERSON COLLECTING YOU AFTER YOUR PROCEDURE *

PHONE NUMBER OF PERSON COLLECTING YOU *

ADDRESS OF THE PERSON COLLECTING YOU AFTER PROCEDURE *

RELATIONSHIP OF PERSON COLLECTING TO PATIENT *

DO YOU HAVE ANY OF THE FOLLOWING ENDURING POWER OF ATTORNEY (If yes to any please bring documentation on the day of the procedure) *

ENDURING POWER OF ATTORNEY – MEDICAL *

Yes No

ENDURING POWER OF ATTORNEY – FINANCIAL *

Yes No

ENDURING POWER OF ATTORNEY – GUARDIANSHIP *

Yes No

NAME OF ENDURING POA

CONTACT TELEPHONE OF POA

MEDICAL HISTORY

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

MUSCULOSKELETAL, MOBILITY AND FALLS

FAINTING, DIZZINESS OR FALLS IN THE LAST 6 MONTHS *

Yes No

DO YOU TAKE FOUR OR MORE PRESCRIBED MEDICATIONS PER DAY (Medication to be listed further in questions) *

Yes No

ARTHRITIS (e.g. osteoarthritis, rheumatoid arthritis) *

Yes No

OSTEOPOROSIS *

Yes No

BACK OR NECK INJURY OR PROBLEMS *

Yes No

PREVIOUS BACK, NECK OR JAW SURGERY *

Yes No

FURTHER INFORMATION ON ANY OF THE ABOVE

GASTROINTESTINAL

REFLUX, HEARTBURN, HIATUS HERNIA, STOMACH ULCERS *

Yes No

BOWEL PROBLEMS (e.g. Crohn’s, IBS, stoma, incontinence) *

Yes No

LIVER DISEASE, JAUNDICE, HEPATITIS *

Yes No

FURTHER INFORMATION ON ANY OF THE ABOVE

SKIN INTEGRITY

PRE-EXISTING WOUNDS OR BREAKS IN YOUR SKIN *

Yes No

ECZEMA, DERMATITIS *

Yes No

FURTHER INFORMATION ON ANY OF THE ABOVE

ENDOCRINOLOGY

THYROID PROBLEMS (e.g. goiter) *

Yes No

How is it managed?

Insulin SGLT-2 inhibitors Diet Controlled

ANAESTHETIC RICK AND OTHER CONDITIONS

HAVE YOU EVER HAD AN ADVERSE REACTION TO ANAESTHETICS *

Yes No

HAS A CLOSE RELATIVE HAD AN ADVERSE REACTION TO ANAESTHETICS *

Yes No

HAVE YOU EVER HAD A DIFFICULT INTUBATION *

Yes No

DO YOU HAVE DENTURES, CAPS, CROWNS, LOOSE TEETH, IMPLANTS OR VENEERS *

Yes No

CANCER CONDITIONS *

Yes No

ANY OTHER CONDITION WE SHOULD BE AWARE OF *

Yes No

HAVE YOU HAD ANY PREVIOUS OPERATIONS OR PROCEDURES *

Yes No

GENERAL HEALTH AND LIFESTYLE

HAVE YOU EVER SMOKED *

Yes No

DO YOU USE RECREATIONAL DRUGS *

Yes No

DO YOU DRINK ALCOHOL *

Yes No

HAVE YOU UNINTENTIONALLY LOST WEIGHT AND/OR HAD A DECREASE IN APPETITE RECENTLY *

Yes No

ARE YOU PREGNANT OR BREASTFEEDING *

Yes No

DO YOU LIVE ALONE *

Yes No

ARE YOU A CARER FOR ANOTHER PERSON *

Yes No

DO YOU CURRENTLY RECEIVE COMMUNITY SERVICE *

Yes No

DO YOU REQUIRE ASSISTANCE WITH DAY TO DAY LIVING *

Yes No

DO YOU HAVE ANY CULTURAL OR RELIGIOUS NEEDS *

Yes No

PROSTHETICS AND AIDS

VISUAL AIDS OR VISUAL IMPAIRMENTS (e.g. glasses, contact lenses) *

Yes No

HEARING AIDS OR HEARING IMPAIRMENTS (e.g. hearing aid, cochlear implant) *

Yes No

ALLERGIES AND ADVERSE REACTIONS (ADR)

DO YOU HAVE ANY ALLERGIES OR ADVERSE REACTIONS TO MEDICATION, TAPES, LATEX, SKIN SOLUTIONS OR FOOD *

Yes No

BOWEL PREPARATION (For colonoscopy procedures only)

HAVE YOU SUFFERED FROM CONSTIPATION IN THE LAST 2 WEEKS *

Yes No N/A having Gastroscopy only

HAVE YOU EXPERIENCED AN UNEXPECTED REACTION TO BOWEL PREPARATION IN THE PAST *

Yes No N/A having Gastroscopy only

HAVE YOU HAD DIFFICULTY CLEARING YOUR BOWELS SUFFICIENTLY IN THE PAST *

Yes No N/A having Gastroscopy only

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) *

Yes No

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.

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 *

Yes No

HAVE YOU HAD COVID *

Yes No

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 *

Yes No

HAVE YOU BEEN INFECTED OR COLONISED WITH A MULTI-RESISTANT ORGANISM SUCH AS MRSA, VRE, CPE *

Yes No

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 *

Yes No

WHAT MATTERS TO YOU

IS THERE ANYTHING THAT MATTERS TO YOU, SPECIFICALLY REGARDING YOUR HOSPITAL STAY THAT WE NEED TO KNOW

DO YOU UNDERSTAND YOUR HEALTHCARE RIGHTS (https://directendoscopy.com.au/your-privacy/) *

Yes No

LEGAL DOCUMENTATION

DO YOU HAVE AN ADVANCED CARE DIRECTIVE(If yes please bring a copy with you)

Yes No

PROCEDURE SAFETY AND RISKS

Complications of gastroscopy are very rare and may include bleeding or perforation. For inspection of the bowel alone, complications of colonoscopy are uncommon.

Most surveys report complications in 1 in 1000 examinations or less.

Complications, which can occur, include an intolerance of the bowel preparation solution and scope disinfection solution used. Perforation (making a hole in the bowel), splenic injury or major bleeding from the bowel is extremely rare but if occurs, may require surgery.

When operations such as removal of polyps are carried out there is a slightly higher risk of perforation and bleeding. Because of the risk of cancer, it is recommended that all polyps found at the time of colonoscopy be removed. However, it will not be possible to discuss the removal with you at the time of examination, as you will be sedated. If you have any queries or reservations about this, please inform your Doctor. In the unlikely event of hemorrhage occurring, blood transfusion may be necessary.

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

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.

PATIENT RESPONSIBILITY AGREEMENT

I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND I UNDERSTAND THE DISCHARGE PLANNING REQUIREMENTS AS ABOVE

EMAIL ADDRESS *

Please tick to confirm that you have read and understood the above

Medication Name	Dose	Frequency	Taking for

Procedure	Date performed

Allergy	Reaction	Date/year of reaction