All fields marked (Required) are required. Please contact Egress Support via support@egress.com if you have any technical issues with completing the form. Please do not share personal / medical information with Egress Support, this is for technical support only, relating to completion of the online form.

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Patient Health Questionnaire

The following questions help us to decide whether we need to see you for a pre-operative check before you are admitted to our hospital. If you need help completing the form or are unsure of the meaning of any of the questions, then please contact the hospital for advice. Please complete the questionnaire fully (giving any further details you feel may be helpful). Please complete the following medical questions as accurately as possible. This is important because it enables us to be informed of any special medical needs you may have and ensures that you are safely prepared for your anaesthetic.

Personal Details

Which number is this?(Required)
Which number is this?(Required)
Which number is this?(Required)
If we need to talk to you about your appointment/treatment, can we contact you by phone and/or leave a message if you are not available?(Required)
Have you had previous treatment at this hospital before?(Required)

Next of Kin Information

Second Contact Information

Do you have any special dietary requirements?(Required)
Do you live alone?(Required)
Any dependents?(Required)
Are you hard of hearing?(Required)
Are you visually impaired?(Required)
Do you have any concerns about your safety at home?(Required)
Do you have any communication problems or special learning needs?(Required)
Is English your first language?(Required)
Do you intend undergoing any form of continuous travel (e.g. car, train, plane) of more than three hours approximately 4 weeks before or after surgery?(Required)
Height unit(Required)
Weight unit(Required)

Health and Social History

Please complete the following medical questions as accurately as possible. This is important because it enables us to be informed of any special medical needs you may have and ensures that you are safely prepared for your anaesthetic.

Please tick yes or no to the following questions and give further details you think may be helpful to us.

Previous Anaesthetics

Have you ever had problems with a previous anaesthetic? if 'yes' or you are not sure, please give details(Required)
Have any of your relatives had problems with anaesthetics? If 'yes' or you are not sure, please give details(Required)

Allergies

Have you ever had a reaction to medicines or other substances (e.g. food/topical agents/latex/metal/other)? if 'yes', give details of what medicine(s)/substance(s) were involved.(Required)
If 'yes', please specify allergies:
Allergy Reaction Action
indicates required field

Alcohol, Smoking/Vaping and Exercise

Do you drink alcohol? if 'yes', please give details(Required)
Do you smoke at present, or have you ever smoked?(Required)
Do you vape at present, or have you ever vaped?(Required)
Would you like to receive some advice on how to give up smoking/vaping?(Required)
Do you take regular exercise?(Required)
Would you like to receive some advice on healthy eating and exercise?(Required)

Medication

Are you currently taking any form of medications (prescribed, herbal, vitamins, recreational drugs or other)?(Required)
If 'yes', please specify medications:
Medication name When Taken Dosage Action
indicates required field
If taking steroids, do you have a Steroid Card?(Required)
In the last 12 months have you taken any medicine for cough, cold or flu containing Pholcodine? (If unsure, hospital will check)(Required)
If 'yes', please specify medications:
Medication name When Taken Dosage Action
indicates required field

Heart Disorders

Do you get chest pain or breathless climbing two flights of stairs?(Required)
Do you suffer with angina more than once each month?(Required)
Have you ever had a heart attack?(Required)
Are you currently being treated for an abnormal heart beat?(Required)
Are you currently being treated for heart failure?(Required)
Have you ever been told that you have a heart murmur?(Required)
Are you being treated for high blood pressure?(Required)
Do you have a cardiac pacemaker or internal cardiac defibrillator?(Required)
Coronary stents and date of insertion(Required)

Breathing Disorders

Do you have asthma, emphysema, chronic bronchitis or any other breathing disorder, including sleep apnoea, cystic fibrosis?(Required)
Do you have asthma attacks more than once each month?(Required)

Brain and Nerve Disorders

Have you been diagnosed as having epilepsy?(Required)
Do you have Parkinsons disease, motor neuron disease, MS, cerebral palsy?(Required)
Do you suffer from fainting, falls or blackouts?(Required)
Have you ever had a TIA or stroke?(Required)
Have you a history of CJD or other prion disease in your family? Or have you been notified that you are at an increased risk of CJD or vCJD for public health purposes? If 'yes', please specify.(Required)
Have you ever had surgery on your brain or spinal cord?(Required)
Have you ever received growth hormone or gonadotrophin treatment?(Required)
Do you suffer with confusion or dementia or have you been diagnosed with Alzheimer's?(Required)

Stomach and Gut Disorders

Do you suffer regularly from indigestion or heartburn?(Required)
Have you ever been treated for a stomach ulcer or hiatus hernia?(Required)
Do you suffer from a bowel condition, e.g. chronic constipation (state laxatives taken) or irritable bowel syndrome or inflammatory bowel disease such as Crohn's disease or ulcerative colitis, or have a stoma?(Required)

Hormone Disorders

Do you have Diabetes?(Required)
Do you have thyroid disease?(Required)

Liver Disorders

Have you ever had jaundice (yellowness of the skin)?(Required)
Have you ever been diagnosed as having hepatitis?(Required)

Bleeding Disorders

Have you ever had a blood transfusion?(Required)
Have you ever been issued with an antibody card?(Required)
Do you refuse to receive blood or blood products?(Required)
Do you bleed or bruise very easily?(Required)
Have you, or a first-degree relative, ever been diagnosed as having a blood clot in the leg (deep vein thrombosis) or in the lung (pulmonary embolus)?(Required)
Have you, or any close relative, been diagnosed with any inherited blood disorder such as sickle cell disease or clotting disorder?(Required)
Have you ever been anaemic?(Required)

Musculoskeletal Disorders

If you sit upright in a chair, do you have difficulties putting your head back far enough to see the ceiling directly above you, while keeping your back straight?(Required)
Have you or a family member ever been diagnosed as having an inherited muscle disease?(Required)
Have you been diagnosed as having arthritis?(Required)
Do you use a mobility aid (e.g. sticks or walking frame)?(Required)

Urinary and Renal Disorders

Have you ever been diagnosed with or treated for acute or chronic kidney disease?(Required)
Are you currently being treated for a urine or bladder infection?(Required)
Do you use a urinary catheter?(Required)

Skin Disorders

Do you currently have any open wounds/ulcers/blisters?(Required)

History of Cancer and / or Transplant

Have you ever been diagnosed as having any type of cancer?(Required)
If 'yes', please specify treatment and type:
Treatment and Type When (year) Action
indicates required field
Have you had an organ/ tissue transplant or stem cell trans-plantation?(Required)

Previous Operations

Have you previously had an operation?(Required)
Operation details:
Please give details (include if you have had any implants or prosthesis inserted) When (year) Were there any complications? If 'yes' please provide further details Action
indicates required field

Other Medical Problems

Is there any other medical or physical condition, not previously mentioned, eg. long COVID, renal dialysis, Downs Syndrome, CPAP, oxygen therapy?(Required)
Do you have a recent history of dental abscess or infections?(Required)
Do you suffer with any anxiety or mental health problems?(Required)

Infection Risks

Have you ever suffered a serious infection(e.g sepsis, clostridium difficile, food poisoning, diarrhoea)?(Required)
Serious infection details:
Infection Type When (year) Area of Infection Action
indicates required field
Have you had both COVID Vaccinations?(Required)
Have you ever tested positive for COVID-19?(Required)
Have you ever been colonised with MRSA or diagnosed with a MRSA infection?(Required)
In the last 12 months have you been an inpatient in a UK hospital?(Required)
In the last 12 months have you been an inpatient in a hospital abroad/outside of the UK? - if so please state name and location(Required)
Have you, or a close contact of yours, been colonised or had an infection with Carbapenemase- producing Enterobacteriaceae (CPE)?(Required)

Female patients only

Are you or could you be pregnant?(Required)
Are you currently breast-feeding?(Required)
Do you take the oral contraceptive pill, take oral HRT, use hormone patches/creams/pessaries, or have hormone/contraceptive implants?(Required)

Declaration

For more information visit our privacy policy.