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  • Level 13, 187 Macquarie Street, Sydney NSW 2000

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Patient Preoperative Assessment Form

DD slash MM slash YYYY
DD slash MM slash YYYY
Time(Required)
:

Please list below all medications you are currently taking, including vitamins and alternative medicines

Time(s) that you take it
Time(s) that you take it
Time(s) that you take it
Time(s) that you take it
Time(s) that you take it
Do you smoke?(Required)
Do you drink Alcohol?(Required)
Females - are you pregnant?(Required)
DO YOU HAVE ANY ALLERGIES e.g. Latex, Medications, Food?(Required)
If yes please list(Required)
Please list previous operations and approximate dates(Required)
Have you had any problems with a local or general anaesthetic previously?(Required)
Do you have a family history of anaesthetic problems?(Required)
Do you have any Healthcare needs that need to be addressed?(Required)
Do you have an Advanced Care Plan?(Required)
Max. file size: 512 MB.
Is there a Support Person that you would like to be involved in your care and decision making?(Required)

Questions relating to Creutzfeldt Jakob Disease

Do you have a family history of two or more first degree relatives with Creutzfeldt Jakob Disease or other unspecified neurological disorder?(Required)
If you have a family history of CJD you would know and have undergone genetic studies identifying if you carry the Gene that pre-disposes you to CJD
Have you received Human Pituitary Hormone prior to 1986? (Growth, Gonadotrophin – for infertility)(Required)
A national register of those patients who have received pituitary hormone exists. Therefore all of these patients know and have received follow up counselling.
Have you had brain surgery? If so please provide further details.(Required)

Questions relating to Candida auris

Have you been hospitalised overseas since 2017?(Required)
Have you or any family members ever been confirmed as a carrier of Candida auris?(Required)

Please indicate which conditions affect or have ever affected you:

Heart Trouble/Heart Attack(Required)
Stroke(Required)
Pacemaker(Required)
Chest Pain(Required)
High Blood Pressure(Required)
Reflux or Indigestion(Required)
Asthma/Breathlessness/Persistent Cough/Lung disease(Required)
Liver Disease/Hepatitis(Required)
Epilepsy/Fits/Blackout/Dizzy Spells(Required)
Diabetes(Required)
Anaemia(Required)
Blood Transfusion(Required)
Bleeding Tendencies(Required)
Back or Hip Problems(Required)
Have you taken Aspirin/Warfarin in the last week(Required)
Steroid/Cortisone in Last 6 months(Required)
Are you in a high risk group for Hep B, C, HIV?(Required)
Do you use any mobility aides?(Required)
Are you at risk of having a fall?(Required)
Do you have any cognitive impairment?(Required)
Do you have any mental health issues?(Required)
Do you have any skin conditions? e.g. Rashes, Blister, Cold Sores, Pressure Sores, MRSA, VRE, Compromised skin integrity(Required)
Consent(Required)
(Required)

Procedures

  • Cataract Surgery
  • Intravitreal Gas
  • Intravitreal Injections
  • Vitrectomy
  • Laser Retinopexy
  • Yag Capsulotomy

Team

  • A/Prof Andrew Chang
  • Dr James Wong
  • A/Prof Samantha Fraser-Bell
  • Dr Thomas Pham
  • Dr Yasser Tariq
  • Our Support Staff

Appointments

  • Patient Consultation
  • For Surgical Patients

Resource Centre

  • Scientific Journal Publications
  • Current Research Trials

Patient Information

  • Eye Conditions
  • Eye Health & Wellbeing
  • Treatments

Contact & Parking

  • Contact Us
  • Parking
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We acknowledge the Traditional Owners and Custodians of the land, the Eora Nation, on which we work and pay our respects to their Elders, both past and present.

Everyone deserves the best care. We foster an inclusive culture by embracing and valuing diversity and equality for our work colleagues and patients. This philosophy extends to everyone we interact with and the communities we serve. You are valued, regardless of race, colour, sexual orientation, gender identity, religion, national origin, ancestry, physical abilities and age.

Home
  • Team
    • Our Doctors
    • Our Support Staff
    • Our Consumer Group
    • Accreditation
  • Appointments
    • Patient Consultation
    • For Surgical Patients
  • Patient Information
    • Eye Conditions
    • Eye Health & Wellbeing
    • Treatments
  • Resource Centre
    • Scientific Journal Publications
    • Current Research Trials
  • Practitioner Referrals
  • Contact
    • Contact Us
    • Parking
Menu
  • Team
    • Our Doctors
    • Our Support Staff
    • Our Consumer Group
    • Accreditation
  • Appointments
    • Patient Consultation
    • For Surgical Patients
  • Patient Information
    • Eye Conditions
    • Eye Health & Wellbeing
    • Treatments
  • Resource Centre
    • Scientific Journal Publications
    • Current Research Trials
  • Practitioner Referrals
  • Contact
    • Contact Us
    • Parking