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DAY-CASE SURGERY ASSESSMENT FORM PATIE NT SELFASSESSMENT

Please answer the following guestions

Have you ever hod:	Yes/No	Social hlstory:		Yes/No
1. Any surgcal operations?	P/P	1. Can someone accompany you home		P/P
PI63S6 Ssl:		in a car or taxi?
	p/p	2. Does/can someone responsible stay		p/p
2. Any aneesthetic or surgical probloms^7		in the hou8e with you post-surgery?
Please k«:		3. Do you have a telephone’		P/P
3. Is there a family htstory of anaesthetic	p/p	4. Do you have easy access 1o a toilet?		p/p
proWems?		5. How many flights of stairs óo you have	P
Please fest:	P/P	10 climb to get to your front door? 6. Do you smoka?		P/P
4. Any other ser«ous illnesaes?		1 = nover
Please W:		2    ■ stopped > 6 months 3    ■ stopped < 6 months 4    =current
Please tick the box if you suffer from any of the		(How many per day?)	P
followmg conditions:		7. Do you drink afcoboT*		p/p
		If you answered yes. how much per week?
1.    Chest pain on exercise or a! n>ght 2.    Asthmj. bronchłt* or sgniticant	P f\
	P
breathmg problems		Surgoon*s assossmcnt
3. High blood pressure	P	1. Diagnosis?
4. Heart murmur	P
S. Fits or faints	P	2. Proposed procedur©?
6. YsRow jaundee	P	3. Anaesthetic proposod?
7. lndi9«*tion.hoartburnof»c»dro«Kjx	P	4. Pfe-operative invest»gation8 required?
8. Diaootos	P	Please tick those reąmfed
9. A/thfrtis or neck problems	P	ECG
10. Anaema or other blood problems	P	(over 60 years ołd or tschaemc heart		P
11. Excessrve bteeding or bru^sing	P	disease. hypertension or long-term diabetes)
12. Kidney or waterwork problems	P
13. Woaknoss of musclos	P	U&Es {on diuretic therapy)		P
14. Do you have a pacemaker'*	P	FBC (hlstory of an3erm»'menorrhagia)
				P
What mcdicincs do you takc? Please lisi.		Sickle (A1ro-Canbbean)		P P
		Other (please specify)
Do you hevo any ollorgios?
		Considered eurtable for day-casc proceduro?		P/P
Please hsl

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