Women's and Children's Hospital

Paediatric PreAnaesthesia Health Questionnaire

Parent/Carer to complete

Please complete and send this form only after your child has been given a date for admission.

This form will only work if you have Email connected to your browser.
When you have completed the form press the send button.
Your browser may warn you that you are sending an Email message to the hospital.
If you are happy with that simply press "continue", "ok" or "accept".

If you do not receive an Email confirming receipt of this form within 3 working days, please phone (08) 81617666.
If you have any problems ring the number on your admission forms.
Please answer ALL questions by ticking the appropriate box and add details if necessary.

To confirm your Child's admission, please phone (08) 81617666, 3 working days prior to admission.

Child's name:

WCH Unit Record (UR) number (if known)

Date of Birth:(Please complete in format eg 08/11/90):

Date of operation/procedure (Please complete in format eg 08/11/90):

Name of operation/procedure:

	Yes	No	?			Yes	No	?
Day surgery patient:					Private patient:

Name of doctor:

Telephone number: (Parent/guardian 9am-5pm)
Home: Work:

What health problems does your child have now?

	Yes	No	?
Has your child had any previous operations or major procedures?

Details:

	Yes	No	?
Has your child had any major illnesses?

Details:

	Yes	No	?
Has your child had previous anaesthetics?
	Yes	No	?
Are you aware of any problems your child has with general anaesthetics?

Details:

	Yes	No	?
Do you know of any problems your child's blood relatives have with anaesthetics?

Details:

	Yes	No	?
Is your child taking any medications, drugs, inhalers or tablets?

Details:

	Yes	No	?
Does your child have any allergies?

Details: (Drugs, food, environment)

	Yes	No	?
Does your child have asthma or any breathing difficulties?

Details:

	Yes	No	?
Does your child snore when asleep?
	Yes	No	?
Has your child had a cold or chest infection recently?

If yes to cold or chest infection list number of weeks ago weeks.

	Yes	No	?
Does your child smoke?

	Yes	No	?
Has your child any heart problems?

Details:

	Yes	No	?
Does your child have diabetes?
	Yes	No	?
Does your child or blood relative have a history of of bleeding or bruising tendencies?

Details:

	Yes	No	?
Was your child born prematurely?

Number of weeks early: weeks

	Yes	No	?
Does your child have any diagnosed disabilities or special needs?

Details:

	Yes	No	?
Have you notified your child's Intervention/Care Agency/Support Service?

Name of Agency/Service:

	Yes	No	?
Does your child have any loose teeth, caps or braces?

Details:

	Yes	No	?
Do you or your child have any questions about anaesthetics?

What are they:

Parent/guardian: name:

Before submitting your form please read it over to check that you have filled in all the fields correctly. This will assist us with the accuracy of the information that we are obtaining on this condition. When you are satisfied the form is completed click this box.

Information accurate

If you are having trouble locaating the required field that you have missed you can use the Find function in your browser to help you. Simply click on Edit at the top of your browser which contains a Find function. You then place the word that you are looking for into this Find function.

By checking the information accuracy box and clicking the Send button I declare that I have given complete and accurate answers to this questionnaire to the best of my knowledge.
I am aware of the danger of food or liquid in my child's stomach during the operation/procedure and agree that my child will have nothing to eat or drink as instructed.