FORM 3 PATIENT HEALTH QUESTIONNAIRE
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1 FORM 3 PATIENT HEALTH QUESTIONNAIRE Return all forms to arrive at Gillies Hospital at least ONE WEEK before admission IMPORTANT: Please send this completed form to the hospital where you will have your procedure/surgery. The hospital needs to receive all three forms at least one week prior to your admission. You can hand deliver, fax, scan and , or post the forms. If you post the forms, please allow 1-2 extra weeks for delivery. Please complete this questionnaire carefully as the information you supply helps us to provide you with the best and safest possible care during your stay at our hospital. The questionnaire has four sections: A Your general health B In preparation for your hospital admission C In preparation for your procedure D Your current medicines - please return even if blank Surname (family name) Height Weight Surgeon metres kilograms NHI (if known) All questions in this questionnaire are about the person being treated at the hospital (the patient). If you are filling this out for the patient, only provide information relating to the patient s health. Section A Your General Health Occupation (optional) A1. MEDICAL PROCEDURE HEALTH ALERTS Do any of the following apply to you? If Yes 1 Difficulty climbing more than a flight of stairs What restricts this activity? 2 Motion sickness mild / moderate / severe (circle one) 3 Jaw problems (difficulty opening mouth) 4 Problems with a previous anaesthetic 5 Family history of problems with an anaesthetic 6 Pacemaker or heart valve replacement 7 Joint implants 8 Other implants or prostheses 9 Substance use or dependency 10 Former smoker When did you quit? 11 Currently on smoking cessation treatment 12 Current smoker How many per day? 13 Pregnant or possibly pregnant Approximate due date: 14 Breastfeeding 15 MedicAlert bracelet or necklace wearer
2 Surname (family name) Section A Your General Health (continued) A2. YOUR MEDICAL CONDITIONS Do you currently have, or have you previously had, any of the following conditions? If Yes, please circle any applicable options and provide comments in the box below. 16 Breathing conditions: asthma wheeziness shortness of breath bronchitis croup emphysema COPD 17 Sleeping conditions: sleeplessness severe snoring obstructive sleep apnoea CPAP used 18 Heart conditions: palpitations irregular heart beat heart murmur angina heart attack chest pain congestive heart failure rheumatic fever - If Yes please provide any relevant specialist letters 19 Stroke or Transient Ischaemic Attack (TIA) 20 High blood pressure or blood pressure controlled with medication 21 Blood clots: deep vein thrombosis (DVT) pulmonary embolus (PE) 22 Family history of blood clots 23 Blood or bleeding conditions: anaemia bruising 24 Family history of blood or bleeding conditions 25 Stomach and digestive conditions: indigestion heartburn acid reflux hiatus hernia peptic ulcer 26 Bowel conditions: irritable bowel syndrome constipation bowel disease 27 Liver disease: jaundice hepatitis 28 Kidney conditions 29 Diabetes: requiring insulin requiring tablets diet controlled 30 Thyroid conditions 31 Parkinson s disease 32 Epilepsy, seizures, blackouts or fainting 33 Migraines or severe headaches 34 Alzheimers or dementia 35 Mental function conditions: head injury concussion confusion or disorientation 36 Mental health conditions 37 Emotional conditions: anxiety phobia post traumatic stress disorder (PTSD) 38 Arthritis 39 Neck or back conditions 40 Gum or dental health conditions 41 Tuberculosis (TB) 42 HIV or AIDS 43 Infection or treatment for resistant organisms: MRSA ESBL VRE OTHER 44 Cancer If Yes, please specify and provide details of any recent treatment in the Comments box below 45 Other condition(s) not listed above - If Yes, please specify in the Comments box below RE QUESTION YOUR COMMENT 20 GP says my blood pressure is slightly high, but am not taking any medicine Example Need more space for your comments? Please continue on a separate sheet and attach it to this page.
3 Surname (family name) Section B In Preparation For Your Hospital Admission B1. YOUR ALLERGIES, SENSITIVITIES, OR INTOLERANCES 46 Are you allergic to latex? 47 Do you have any other allergies, sensitivities or intolerances? If Yes, please specify and describe the reaction using the box below Skinrelated Item Reaction Plasters Example Rash Example Medicinerelated Foodrelated Other B2. YOUR NEEDS AND PREFERENCES Please answer these questions to help us to tailor how we care for you. If you answer Yes to any of these questions, we may contact you to discuss your specific needs. If Yes 48 Do you have a disability? 49 Do you have difficulty understanding English? Your preferred language: 50 Do you have any religious or spiritual needs you would like us to know about? 51 Do you have any cultural or family needs you would like us to know about? 52 Do you have any other special needs you would like us to know about? 53 If your procedure requires the removal of body parts, would you like them returned to you if this is possible? 54 Do you have any dietary requirements? 55 Do you have any specific food dislikes? For allergies or intolerances, refer to question 47 vegetarian vegan diabetic gluten free halal dairy free breast fed bottle fed other
4 Surname (family name) Section C In Preparation For Your Procedure C1. MEDICAL PROCEDURE HISTORY 56 Have you previously had any procedures / operations or other hospital admissions? If Yes, please outline your previous admissions in the table below. If you need more space, please continue on a separate sheet and attach it to this page Procedure or event Year Hospital C2. ANAESTHESIA CONSIDERATIONS 57 Have you had an anaesthetic before? general spinal epidural unsure 58 Do you have any of these dental features? upper denture lower denture crown(s) / cap(s) partial plate loose or chipped teeth 59 Do you drink alcohol? How much? C3. PERSONAL ITEMS Do you use any of these personal items? If Yes, use this space to provide details, if needed 60 Mobility aids, such as a walking stick or cane 61 Glasses or contact lenses 62 Hearing aids 63 Earrings or other piercing jewellery C4. BLOOD CLOT AND INFECTION CONSIDERATIONS 64 Have you completed the pre-admission risk assessment in the Blood Clots and YOU brochure? 65 Have you recently been on a long distance flight? 66 In the past 3 days, have you had, or been in contact with anyone who has had, vomiting or diarrhoea? 67 In the past 7 days, have you experienced flu-like symptoms, or been in contact with anyone diagnosed with influenza? 68 In the past 4 weeks, have you had a head cold, throat or chest infection, or bronchitis? 69 In the past 12 months, have you travelled overseas? If yes where? 70 In the past 12 months, have you been a patient or employee in a rest home or hospital in New Zealand or overseas? If yes where? 71 Do you have any boils, cuts, sores, scratches or other skin or urine infections? C5. OTHER CONCERNS 72 Is there anything we need to know that you prefer not to write on this questionnaire? If Yes, please discuss with your nurse or medical specialist when you arrive at the hospital 73 Do you have anxieties, concerns, or questions you wish to discuss before your procedure? If Yes, who would you like to speak with? your surgeon your anaesthetist a nurse one of our admin. staff
5 Surname (family name) Section D Your Current Medicines For your safety, it is extremely important that your doctors and nurses know precisely which medicines you are currently using. Please return this page even if you are not on any regular medication and it is blank. There are many types of medicine MEDICINE REMINDERS Which of the examples below apply to you? Medicines come in many forms Medicines are taken for many common conditions Important instructions. 1. List below all medicines you currently use, and bring them with you to the hospital in their original containers 2. To ensure you are clear what to include, please use the MEDICINE REMINDERS table (right ) 3. If you have a medication card or printout from your GP or pharmacist, please bring it with you to the hospital, as well as completing the list below. prescription medicines vitamins herbal medicines supplements natural medicines contraceptives homeopathic remedies steroids over-the-counter medicines tablets patches capsules suppositories inhalers creams drops injections syrups other liquids heart disease infections high blood pressure diabetes blood thinning sleeplessness dietary deficiencies epilepsy emotional conditions D1. YOUR CURRENT MEDICINES HOSPITAL USE ONLY Patient to complete list all medicines you currently use. Reconciled: Yes (Y) No (N) Not available (NA) Name of medicine Strength How much you use, and when Medicine container Medication card Patient or whanau/ family Other (state) eg, phoned GP Comment if No ON ADMISSION: Date/time last taken Paracetamol Example mg 2 capsules every 6 hours If required, please continue on the reverse This is not a prescription or an instruction to administer medicines
6 Surname (family name) Section D Your Current Medicines (continued) Continued from reverse. D1. YOUR CURRENT MEDICINES HOSPITAL USE ONLY Patient to complete list all medicines you currently use. Reconciled: Yes (Y) No (N) Not available (NA) Name of medicine Strength How much you use, and when Medicine container Medication card Patient or whanau/ family Other (state) eg, phoned GP Comment if No ON ADMISSION: Date/time last taken This is not a prescription or an instruction to administer medicines
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