PRE-ADMISSION SURGICAL PATIENT REGISTRATION - Castlemaine Campus

Help us to ensure that your booking is successful by immediately completing this online form. Upon completion, you will receive an email to confirm we have received your information.

Help us to ensure that your booking is successful by immediately completing this online form.
Upon completion, you will receive an email to confirm we have received your information.

Please enter the password provided to you by Castlemaine Health for online form entry

Password

Surgeon

Please provide surgeon's name

Date of Surgery. **Press Enter key or click in entry box after picking from calendar, then check correct date is displayed.

PATIENT

Other title:

Family Name (as on Medicare card) *

Given Names *

Previous Surname (if applicable)

Preferred Name (if different to Medicare card)

Country of Birth *

Sex at Birth *

FemaleMaleAnother Term

Date of Birth. **Press Enter key or click in entry box after picking from calendar, then check correct date is displayed. *

Marital Status *

Preferred Language

Interpreter Required?

YesNo

Indigenous Status *

AboriginalTorres Strait IslanderBothNeither

Residential Address *

Postal Address if different to residential address

Home Phone (Landline or Mobile) *Please enter with spaces eg. home xxxx xxxx or mobile 04xx xxx xxx

Mobile Phone (if different to Home)Please enter with spaces eg. 04xx xxx xxx

Work PhonePlease enter with spaces eg. home xxxx xxxx or mobile 04xx xxx xxx

Email Address *

GP Name

GP Clinic *

NEXT OF KIN OR PRIMARY CONTACT

Name *

Address *

Phone *Please enter with spaces eg. home xxxx xxxx or mobile 04xx xxx xxx

MobilePlease enter with spaces eg. 04xx xxx xxx

Relationship *

Do you have a Medicare card?

Medicare No. WITHOUT SPACES

Position on card

Expiry month

year

Pension No. WITHOUT SPACES

Pension Expiry

Health Care No. WITHOUT SPACES

Health Care Expiry

Safety Net Card No. WITHOUT SPACES

Safety Net Expiry

Safety Net Card held by pharmacy?

If so, name of pharmacy

DVA No.

DVA colour

GoldWhiteOrange

Workcover No.

Employer Name and Address

TAC No.

Private Health Fund

Membership Number

List below all medications you are currently taking (ie puffers, patches, injections, tablets, herbal supplements, laxatives)

Name of Medication

Dose

Frequency

Reason for taking the medication?

If you have additional medications, please bring your list or add to the additional information box at the end of this form.

Are you allergic to any medications, adhesive tapes, foods or latex? If yes, describe:

Have you recently taken any of these steroid medications? (if yes, tick box and include in medications list above)

CortisonePrednisolone

Do you take blood thinning medication? (If yes, enter INR level, tick box(es) below and include in medications list above)

Please specify other blood thinning medication

Do you have a pacemaker?

If so, what type is it?

When was it last checked?

Cardiologist

How tall are you (in centimetres) *

How much do you weigh (kg) *

Are there any legal directives in place for providing consent? eg guardianship, court order, medical teatment decision maker.

If so please provide details

Do you have an Advanced Care Directive? (please bring a copy with you to hospital)

Do you object to having a blood transfusion/blood products if required?

Have you ever had any of the following? If so, please tick the appropriate box and provide a short description.

Heart surgery

eg stents, angioplasty, bypass, valve replacement

Lung surgery

eg lobectomy, wedge resection, removal of lung

Spinal surgery

eg discectomy, spinal fusion, laminectomy/laminotomy

Head, Neck surgery

eg cleft palate, tracheostomy, Oral and maxillofacial surgery

Other major surgery

major surgery not covered above eg nephrectomy, abdominal, joints

Have you or a relative had problems with a previous anaesthetic, operation or with malignant hyperthermia?

Are there any health conditions that run in the family?

If yes, describe

Do you have dietary restrictions?

Have you been put on a special diet?

If yes, describe

Do you currently smoke?

Total no. per day

If an ex-smoker, when did you cease?

Do you drink alcohol?

Per week; approx how many, what size, what type?

Do you take/smoke recreational substances?

If yes, describe

Frequency

Are you able to walk 1km?

Do you use a mobility aid?

Walking Stick

Frame

Scooter

Do you do your own:

Housework

Shopping

Woodchopping

Lawnmowing

Do you have care responsibilities for others?

Do you have any self care problems?

Do you receive any community services?

Has anyone in your family done something that made you (or your children) feel unsafe or afraid ?

If you are a female patient

Are you currently breastfeeding?

Could you be or are you pregnant?

If pregnant, how many weeks

For a same day stay, it is essential that you have a support person to stay with you after discharge and overnight - Has this been organised?

Who is your escort home? Must be a fully qualified driver. Name

Phone numbersPlease enter with spaces eg. home xxxx xxxx or mobile 04xx xxx xxx

Do you currently have or have you ever had any of the following conditions (tick the appropriate box)

RESPIRATORY

Shortness of Breath

Asthma

Bronchitis

Pneumonia

Emphysema

Tuberculosis

COPD

Lung disease

Sleep Apnoea

Snoring

Disturbed Sleep

CPAP/BPAP

Chronic Respiratory Failure

Bronchiectasis

When was your last appointment with a Respiratory Specialist? Give date if known, or "x weeks\months ago" if unsure.

ENDOCRINE\METABOLIC

Diabetes -----------------------------

Type 1

Insulin controlled

Type 2

Diet Only

Tablets Only

BSL Range

Insulin Only

Tablets & Insulin

(If tablets or insulin ticked, make sure that they are included in the medication list)

Thyroid disease

Thyroxin level

Cystic Fibrosis

CARDIOVASCULAR

Angina

Chest Pain

Irregular Heart Beat

Rheumatic Fever

Heart Murmurs

Palpitations

Ischaemic Heart Disease

Chronic Heart Failure

CIRCULATORY

High Blood Pressure

Bleeding Tendency

Low Blood Pressure

Anaemia

Coronary Artery Disease

Blood Disorders\Diseases

Blood clots in ------------------------

Lungs

Legs

Blood Transfusion in Year(s)

GENITO URINARY

Chronic Kidney Disease

CKD Stage

Bladder Problems

MUSCULOSKELETAL

Rheumatoid Arthritis

Osteo Arthritis

Neck Problems

Back Problems

Hip Problems

Jaw Problems

Osteoporosis

Muscle Disorder

Muscular Dystrophy

Spina Bifida

Systemic Lupus Erythematosus

Fibromyalgia

MND

NERVOUS SYSTEM

Blackouts

Epilepsy

Fits

Stroke

Parkinson's Disease

TIA

Multiple Sclerosis

Cerebral Palsy

Plegia (eg: Tetraplegia, Paraplegia, Diplegia, Monoplegia, Hemiplegia)

DIGESTIVE

Hepatitis

Type

Jaundice

Chronic Liver Disease

Reflux

Stomach Ulcers

Crohn's Disease

Ulcerative Colitis

Gastro-Oesophageal Reflux Disease

MENTAL\BEHAVIOURAL

Anxiety

Mental Health Problem

Depression

Intellectual Development Disorder

Dementia

Autism

Down's Syndrome

ADHD

Schizophrenia

Other Mental\Behavioural

Other Medical Condition not described above? (eg cancer)

INFECTION CONTROL RISK SCREEN

A recent admission to an Australian health care facility within the last 4 weeks

Direct transfer, overnight stay in hospital or residential care facility overseas in the last 12 months

Any contact with an infectious person

Any discharging or infected wounds or exfoliating skin disorder?

Any current symptoms of an infectious illness

Diarrhoea

Vomiting

Febrile illness

Rash

Persistent cough

Flu-like symptoms

Ebola

A current indwelling invasive device eg PICC, Portacath, IDC, IV, Cannula?

Any current or recent symptoms of communicable infectious disease eg measles, chicken pox, pertussis?

A history of Creutzfeld Jakob Disease (CJD)?

A multi-resistant organism infection or colonisation eg MRSA, VRE, C Difficile, ESBL, CPE?

Currently immunosupressed (Neutrophils <1.0 10g/L)

ADDITIONAL INFORMATION. Is there anything else that you would like to tell us that has not been covered above?

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