Patient Details


About you

Do you wear contact lenses?
Any body piercings?
Any loose teeth, crowns or plates?

Surgical History

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

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


Have you ever suffered from asthma?*


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

Obstructive Sleep Apnoea

Do you have obstructive sleep apnoea or snore?*


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


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


Have you ever had liver disease?*


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


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


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

Neck problems

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


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


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


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

Mental health and memory loss

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


Have you an under or over active thyroid?*

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)*


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


Please tick if you have or have had any of the following infections:
HepatitisHIVMalariaPseudomonasTuberculosis (TB)SARSMRSAWound or leg infection in the past six months
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:


Have you had falls?*

Do you have mobility problems or need mobility aids?*

Needle Phobia

Do you have a needle phobia?*

Additional details

If there is anything else that is not covered in the questions above, which you feel we should know, please give further details below:


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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