Pre-assessment form

We are delighted that you have chosen MyBreast for your operation.

We would be grateful if you would spend a few minutes completing this questionnaire as soon as possible. This will then be reviewed by our Pre-assessment Nurse. It is important you follow our recommendations on isolating between now and your admission.

We recommend you to isolate for seven days prior to your procedure with the exception of having your Covid swab taken.

Failure to complete this questionnaire may result in your procedure being cancelled one the day. The Pre-assessment Nurse will liaise with your consultant anaesthetist to decide whether any further tests or investigations are needed, and to ensure your anaesthetic is the safest possible.

If you have any questions, please contact the Pre-assessment Nurse on: 0203 642 1490

Select A Hospital

Weymouth Street Hospital

Phoenix Hospital Chelmsford

Harley Health Village

The London Welbeck Hospital

Spire Clare Park Hospital

Other

COVID 19 Information

The following questions are designed to keep the hospital, patients and staff as free as possible from COVID-19. It is essential you answer them as truthfully as possible. We will be happy to discuss your concerns. If you have any of the following symptoms prior to your admission please contact our Pre-assessment team to discuss the best way to proceed; new continuous cough, high temperature, shortness of breath or loss or taste and smell.

Vaccination status*

Unvaccinated

1st vaccine completed

2nd vaccine completed

Have you ever tested POSITIVE for COVID-19?* (Lateral flow or PCR)

Yes

If yes, what date did you test positive?

Do you have any ongoing symptoms or complications from your COVID-19 infection? (Cough, shortness of breathe, fatigue)

Yes

If you answered yes to the above question please give a detailed explanation.

Patient Details

Title*

First Name*

Last Name*

Date of Birth*

Email*

Phone Number*

Under which surgeon?*

Proposed Surgery?*

Date of Operation*

Your insurance company if you are claiming fees back

Next of Kin Name*

Next of Kin Number*

About You

Do you smoke cigarettes or vape?

Yes

Do you drink alcohol?

Yes

If you answered yes, how many units per week?

Do you take recreational drugs?

Yes

Do you have vision or hearing impairment? (Do you wear glasses or hearing aids?)

Yes

If you answered yes, please specify (If you wear contact lenses, please bring a pair of glasses on the day of your operation)

Have you had any dental work performed in the last 6 months?

Yes

If you answered yes, please specify.

Any body piercings?

Yes

Any loose teeth, crowns or plates?

Yes

Your weight (in either kilograms or stones)*

Your height (in centimeters or inches)*

Surgical History

Have you ever been to Weymouth Street Hospital or Phoenix Hospital Chelmsford before?

Yes

Have you ever had an operation?*

Yes

If Yes, please list your previous operations (Please provide dates for your procedures)

Have you ever had a general anaesthetic? (i.e this is where you have been unconscious)*

Yes

If you answered Yes above, when was your last general anaesthetic?

Have you or a relative ever had a problem with an anaesthetic?

Yes

Who had the problem? Yourself, a parent, grandparent etc.

Asthma

Have you ever suffered from asthma? *

Yes

Please tick all that apply:

I only had asthma in childhood

I developed asthma as an adult

I have had an attack in the past four weeks

My asthma is stable

I have needed emergency help for an asthma attack

Please give further details if you answered 'Yes' to the last question.Please include dates (dd/mm/yyyy)

Respiratory

Do you have any lung problems? (Include chronic diseases and shortness of breath) *

Yes

Please tick all that apply:

I produce sputum every winter

I have been diagnosed with bronciectasis or emphysema

I have had lung cancer

I have had an operation on my lungs

I get short of breath on moderate exercise

I need oxygen

I have other lung problems

Please provide any further information

Obstructive Sleep Apnoea

Do you snore*

Yes

Have you been diagnosed with Obstructive Sleep Apnoea?*

Yes

Do you snore loudly?

Yes

What is your collar size? (inches)

Do you feel tired, fatigued or sleepy during the day?

Yes

Has anyone observed you to stop breathing during your sleep? (Partners often report the person snores, then is silent for a few seconds)

Yes

Please provide as much information as possible.

Cardiovascular

Have you ever had heart disease, high blood pressure, chest pain or heart palpitaions?*

Yes

Please tick all that apply:

I have high blood pressure and / or I am taking tablets for hypertension

I have had angina

I have had a heart attack

I have had heart bypass surgery

I have heart valve problems or had a valve operation

I have heart failure

I have or have had atrial fibrillation

I have or have had other arrythmias (irregular heart beats)

I have had an ablation

I have an aneurysm or have had aneurysm surgery

I have had an ECHO in the last year

Do you have any of the following?

A pacemaker

An indwelling defibrillator

A plain stent

A drug eluting stent

A heart valve replacement

Please provide as much information as possible.
The dates and results of any investigations would be helpful (dd/mm/yyyy)

Renal

Have you ever had kidney, urinary or prostate problems?* (Women can exclude up to 3 urinary tract infections)

Yes

Please tick all that apply:

Do you have renal failure (kidney failure)?

Are you on dialysis?

Have you had a kidney transplant?

If you are male, do you have prostate problems. Frequency, poor stream, difficulty passing urine, getting up at night to urinate?

Yes

Please tick if you have you had:

Prostate cancer

Surgery to remove your prostate

Radiotherapy

Chemotherapy

Ultrasound treatment

Please provide as much information as possible.

Hepatic

Have you ever had liver disease?*

Yes

Please tick all that apply:

I have had jaundice (other than at birth)

I have had hepatitis

I have cirrhosis

I have liver failure

Please provide as much information as possible.

Pancreas

Have you ever had pancreatitis?* (Please include cysts and pancreatic cancer)

Yes

Gastrointestinal

Have you ever had indigestion or stomach problems?* (This includes reflux, heartburn & ulcers)

Yes

Please tick all that apply:

I have indigestion or heartburn

I get a nasty taste and / or fluid in my mouth if I lie down or bend over

I have had an endoscopy (camera investigation)

I have or had an ulcer

I have been diagnosed with reflux

I have had surgery

Please provide as much information as possible.

Diabetes

Have you ever had diabetes?* (Please include diabetes in pregnancy)

Yes

Please tick all that apply:

I have been on insulin

I am on insulin

I have been on diabetic tablets

[checkbox diabetes-d use_label_element 'I have had low blood sugar ('hypos') in the last year']

My diabetes is well controlled

I have had my eyes examined in the last year

I have had a HbA1c result within the last 3 months

I have kidney complications

I have diabetic leg ulcers or poor blood supply in my legs

My diabetes is well controlled

Please provide as much information as possible. If you are on insulin, this will need to be modified before your operation and the Pre-assessment nurse will contact you

Neck problems

Have you ever had neck problems?* (Please include trauma, ankylosing spondylitis and an increasingly stiff neck)

Yes

Please tick all that apply:

I have a painful neck

I have a stiff neck

I have had a whiplash injury

I have rheumatoid arthritis affecting my neck

I have ankylosing spondylitis

I find it difficult to look up or look behind me

I have had neck surgery or injections into the spine

Please provide as much information as possible. If you are on insulin, this will need to be modified before your operation and the Pre-assessment nurse will contact you

Clotting

Have you had bleeding problems or clots?* (This includes DVT, pulmonary embolus, Factor V Leiden and Haemophilia)

Yes

Please tick all that apply:

I have had a deep vein thrombosis

I have had a pulmonary embolus

I have been on anticoagulants (blood thinners)

I am still on anticoagulants

I have a clotting problem such as factor V Leiden

I bleed or bruise easily and have a bleeding problem such as haemophilia or factor X deficiency

I am under the care of a Haematologist

Please provide as much information as possible.

Haematology

Have you had anaemia, blood problems or leukaemia?* (Please include sickle cell, thalassaemia and other inherited problems)

Yes

Please tick all that apply:

I have had anaemia or low iron

I am currently anaemic

I take iron tablets

I have had leukaemia or lymphoma

I have sickle trait

I have thalassemia trait

I have thalassemia

I have a family history of these problems but have not been tested

I am under the care if a haematologist

Please provide as much information as possible. If you have a recent haemoglobin test result please provide the result

Neurology

Have you ever had fits, a stroke, TIA (mini stroke), brain tumour, blackouts/fainting or receive treatment from a Neurologist?*

Yes

Please tick all that apply:

I have had fits

I am currently epileptic and/or take drugs to control fits

I have had a stroke

I have had or may have had a mini stroke (transient ischaemic attack)

I have had brain surgery

I have had a head injury requiring intensive care

I have seen a neurologist

I have had Multiple Sclerosis

[checkbox neurology-i use_label_element 'I have had Parkinson's Disease']

I have had Muscle Weakness

I have had Difficulty Swallowing

I have had Fainting/Blackouts

Please give further details.

Mental Health and Memory Loss

Have you ever had bipolar, depression, schizophrenia, claustrophobia or memory loss?*

Yes

Please tick all that apply:

I have suffered from bipolar disease (depression)

I have schitzophrenia

I have been under a psychiatrist

I suffer from claustrophobia

I have memory loss

I need my partner or family to help me make decisions

Please provide further details if possible.

Thyroid

Have you an under or over active thyroid? *

Yes

Please tick all that apply:

I have an underactive thyroid

I have a specific diagnosis (e.g. Hashimotos, Graves)

I take thyroxine

I have an overactive thyroid

I have had a thyroid mass or thyroid surgery

Please provide as much information as possible. IF YOU ARE ON THYROXINE PLEASE ASK YOUR GP FOR YOUR LATEST BLOOD TEST AND BRING IT INTO HOSPITAL

Medication and Drugs

Are you taking any medication? Have you taken steroids in the last three months? Please include over the counter and recreational drugs , vitamins and Chinese herbs *

Yes

Please list all the drugs you are taking. The dosage would be helpful, especially if you are on insulin

Allergies

Are you allergic to any drugs, medicines, foods or LATEX?* (Include anything that causes a rash, wheezing, difficulty breathing or anaphylactic shock)

Yes

If yes, please provide details. Please state the name of the drug or allergen and what reaction you had. Your GP may be able to assist you if you cannot remember.

Infections

Please tick if you have or have had any of the following infections

Hepatitis

HIV

Malaria

Pseudomonas

Tuberculosis (TB)

SARS

MRSA

Wound or leg infection in past six months

VRE (Vancomycin-resistant Enterococcus)

CPE (Carbapenemase Producing Enterobacteriaceae)

Please tick if any of the below apply to you

I have an open wound

I am a healthcare professional

Contact with other communicable infections in last three months

I have spent more than 24 hours in a UK or overseas hospital in the last 12 months

Please state the hospital or country

Please provide as much information as possible.

Mobility

Have you had falls?*

Yes

Can you lay flat?

Yes

Do you have mobility problems or need mobility aids? *

Yes

Please provide as much information as possible.

Needle Phobia

Do you have a needle phobia?*

Yes

Additional Details

Are you under any specialists doctors or your GP for current investigations?*

Yes

If you answered yes to the above, please specify.

Will you be on your period during your hospital admission?*

Yes

Are you currently breastfeeding?*

Yes

Do you have any dietary requirements (Kosher, vegan, vegetarian, coeliac?)*

Yes

If you answered yes to the above, please specify.

Are you a private or NHS patient?*

Private

NHS

If there is anything else that is not covered in the questions above, which you feel we should know, please give further details below:

Statement

Please type your name and press the submit button. The questionnaire will go to our Pre-assessment nurse who will coordinate with your consultant anaesthetist. We will contact you if we need any further information or require any further tests.

Thank you for your help and we hope you have a comfortable stay at Phoenix Hospital Group.

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First Name*

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