Pre-assessment

Pre-Assessment

COVID 19 Information

The following questions are designed to keep the hospital, patients and staff as free as possible from COVID-19. It is essential you answer them as truthfully as possible. We will be happy to discuss your concerns.

Have you currently or in the previous 14 days had a temperature, cough, muscle pains, malaise, shortness of breath or loss of taste or smell?*
YesNo

Have you been advised to have a PCR swab?* (Excluding having a swab as part of Pre-assessment for your procedure)

Has anyone in your household or anyone you have been in close contact with had any of the above symptoms within the last 14 days?*
YesNo

Have you had a PCR (nasal and throat swab) test for COVID-19?*
YesNo

If you answered yes to the above question please state when, why and what the result was from the test.

(If you haven’t already had your Pre-op swab, please advise the date you will having your Covid swab prior to your surgery)

If you use a COVID-19 app, have you had any alerts in the last 14 days?*
YesNo

Is there any other reasons you believe you may have contracted or been exposed to COVID-19 in the last 14 days?*
YesNo

If you answered yes to the above question please give a detailed explanation.

Patient Details


MrMrsMsMissDr

About you

Do you smoke cigarettes or vape?*
YesNo
Do you drink alchohol?*
YesNo
Do you take recreational drugs?*
YesNo
Do you have vision or hearing impairment? (do you wear glasses or hearing aids?)?*
YesNo

(If you wear contact lenses, please bring a pair of glasses on the day of your operation)
Have you had any dental work performed in the last 6 months?*
YesNo
Any body piercings?*
YesNo
Any loose teeth, crowns or plates?*
YesNo

Surgical History

Have you ever been to Phoenix Hospital Chelmsford before?*
YesNo
Have you ever had an operation before?*
YesNo

Have you ever had a general anaesthetic? (i.e. this is where you have been unconscious)*
YesNo

Asthma

Have you ever suffered from asthma?*
YesNo

Respiratory

Do you have any lung problems? (include chronic diseases and shortness of breath)*
YesNo

Obstructive Sleep Apnoea

Do you snore?*
YesNo
Have you been diagnosed with Obstructive Sleep Apnoea?*
YesNo
Please answer these questions if you answered "yes" to either of the above.

Do you snore loudly?
YesNo
Do you feel tired, fatigued or sleepy during the day?
YesNo
Has anyone observed you to stop breathing during your sleep? (Partners often report the person snores, then is silent for a few seconds)
YesNo

Cardiovascular

Have you ever had heart disease or high blood pressure? (Please include investigations such as cardiac catheterisation, pacemakers and heart operations)*
YesNo

Renal

Have you ever had kidney, urinary or prostate problems? (Women can exclude up to 3 urinary tract infections)*
YesNo

Hepatic

Have you ever had liver disease?*
YesNo

Pancreas

Have you ever had pancreatitis? (Please include cysts and pancreatic cancer)*
YesNo

Gastrointestinal

Have you ever had indigestion or stomach problems? (This includes reflux, heartburn and ulcers)*
YesNo

Diabetes

Have you ever had diabetes? (Please include diabetes in pregnancy)*
YesNo

Neck problems

Have you ever had neck problems? (Please include trauma, ankylosing spondylitis and an increasingly stiff neck?)*
YesNo

Clotting

Have you had bleeding problems or clots? (This includes DVT, pulmonary embolus, Factor V Leiden and Haemophilia)*
YesNo

Haematology

Have you had anaemia, blood problems or leukaemia? (Please include sickle cell, thalassaemia and other inherited problems)*
YesNo

Neurology

Have you ever had fits, a stroke, TIA (mini stroke), brain tumor or receive treatment or seen a Neurologist?*
YesNo

Mental health and memory loss

Have you ever had bipolar disease (depression), schizophrenia, claustrophobia or memory loss?*
YesNo

Thyroid

Have you an under or over active thyroid?*
YesNo

Medication and drugs

Are you taking any medication? Have you taken steroids in the last three months? (Please include over the counter and recreational drugs, vitamins and Chinese herbs)*
YesNo

Allergies

Are you allergic to any drugs, medicines, foods or LATEX? (Include anything that causes a rash, wheezing, difficulty breathing or anaphylactic shock)*
YesNo

Infections

Please tick if you have or have had any of the following infections:
HepatitisHIVMalariaPseudomonasTuberculosis (TB)SARSMRSAWound or leg infection in the past six monthsVRE (Vancomycin-resistant Enterococcus)CPE (Carbapenemase Producing Enterobacteriaceae)
Please tick if any of the below apply to you:
I have an open woundContact with other communicable infections in the last three monthsI am a healthcare professionalI have spent more that 24 hours in a UK or overseas hospital in the last 12 months
Please state the hospital or country:
Please provide as much information as possible:

Mobility

Have you had falls?*
YesNo

Do you have mobility problems or need mobility aids?*
YesNo

Needle Phobia

Do you have a needle phobia?*
YesNo

Additional details

Are you under any specialists doctors or your GP for current investigations?*
YesNo
If you answered yes to the above, please specify.
Will you be on your period during your hospital admission?*
YesNo
Are you currently breastfeeding?*
YesNo
If there is anything else that is not covered in the questions above, which you feel we should know, please give further details below:

Statement

Please type your name and press the submit button. The questionnaire will go to our Pre-assessment nurse who will coordinate with your consultant anaesthetist. We will contact you if we need any further information or require any further tests. You are welcome to telephone the hospital on 01245 801234 if you have any questions. Thank you for your help and we hope you have a comfortable stay at Phoenix Hospital Chelmsford.

Type your name below to accept*

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