Complete this questionnaire at home before your pre-assessment appointment. When you reach the end, you can print your summary or email it directly to your clinic. Bring a copy to your appointment.
Pre-anaesthetic health questionnaire
This form helps your anaesthetist prepare for your care. Please answer all questions as accurately as you can. It should take about 10–15 minutes.
This helps us provide care that is right for you and is used for health planning in New Zealand.
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Māori
✓
Samoan
✓
Tongan
✓
Cook Island Māori
✓
Niuean
✓
Fijian
✓
Other Pacific peoples
✓
Chinese
✓
Indian
✓
Other Asian
✓
New Zealand European / Pākehā
✓
Other European
✓
Middle Eastern / Latin American / African
✓
Other ethnicity
Please specify
An EPOA is a legal document that allows someone to make decisions on your behalf if you are unable to do so.
Yes — I have an EPOA for personal care and welfare
No
Not sure
Name of EPOA holder
Relationship to you
Contact phone number
Height (cm)
Weight (kg)
Section 1 — Medical history
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Heart disease or angina
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Atrial fibrillation or irregular heartbeat
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High blood pressure
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Diabetes
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Asthma or COPD
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Kidney or liver disease
✓
Stroke or neurological condition
✓
Reflux or heartburn (GORD)
✓
None of the above
Heart disease — please tell us more
Yes
No
Approximate date and any treatment received
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Coronary stent(s)
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Bypass surgery (CABG)
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Heart valve surgery
✓
Pacemaker or ICD (defibrillator)
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None
No symptoms with ordinary activity — I can do what I normally do without any limitation
Slight limitation — I am comfortable at rest but get symptoms with moderate effort (e.g. climbing stairs or walking uphill)
Marked limitation — I am comfortable at rest but get symptoms with minimal effort (e.g. walking on the flat)
I get symptoms at rest or with any activity
Diabetes — please tell us more
Type of diabetes
Type 1
Type 2
Not sure
How is your diabetes managed?
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Diet only
✓
Tablets (e.g. metformin)
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Insulin injections
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Insulin pump
Most recent HbA1c (if known)
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Pacemaker
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ICD (implanted defibrillator)
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Neurostimulator / spinal cord stimulator
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Cochlear implant
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Insulin pump
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Other
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None
Please describe
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Section 2 — Medications
Yes
No
Please list all medications and doses
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Warfarin
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Aspirin
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Clopidogrel (Plavix)
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Ticagrelor (Brilinta)
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Rivaroxaban (Xarelto)
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Apixaban (Eliquis)
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Dabigatran (Pradaxa)
✓
Other
✓
None
Please specify
Yes
No
Please select all that apply
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Cannabis
✓
Cocaine
✓
MDMA / ecstasy
✓
Methamphetamine
✓
Opioids (not prescribed)
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Other
How often and when last used?
None
Occasional (less than weekly)
Moderate (1–14 drinks per week)
Heavy (more than 14 drinks per week)
Approximate number of drinks per week
Never smoked
Ex-smoker
Current smoker
Vaping only
Smoke and vape
How many per day?
For how many years?
If ex-smoker, when did you stop?
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Section 3 — Allergies
Yes
No
Please list the substance and the reaction you had
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Section 4 — Previous anaesthesia
Yes
No
Please list the operations you have had
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Nausea or vomiting
✓
Awareness during surgery
✓
Allergic or unexpected reaction
✓
Severe post-operative pain
✓
No problems
Yes
No
Unknown
Please describe the problem and which relative
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Section 5 — Airway & dental
Yes
No
Not sure
Please describe what you were told, and when
Do you have an airway alert card?
Yes
No
✓
Crowns, bridges, or veneers
✓
Loose or broken teeth
✓
Dentures or removable retainer
✓
None of the above
Please describe (e.g. which teeth, upper or lower denture)
✓
Difficulty opening mouth wide
✓
Neck stiffness or limited movement
✓
Beard
✓
None of the above
Sleep apnoea — please tell us more
Have you been formally diagnosed with obstructive sleep apnoea (OSA)?
Yes — formally diagnosed
Suspected but not formally tested
No — just snoring
Do you use a CPAP machine?
Yes — I will bring my machine to hospital
Yes — but I won't be bringing it
No
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Section 5 — DASI: Cardiac fitness
Tick everything you can do, even if you choose not to.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No / not applicable
Yes
No
Yes
No
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Section 7 — STOP-BANG: Sleep apnoea screening
These questions help screen for obstructive sleep apnoea, which can affect how anaesthesia is managed.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Additional screen — Epworth Sleepiness Scale
Because your answers suggest a higher risk of sleep apnoea, we are asking a few more questions about daytime sleepiness. For each situation below, rate your chance of dozing off using the scale: 0 = would never doze, 1 = slight chance, 2 = moderate chance, 3 = high chance.
0 — would never doze
1 — slight chance
2 — moderate chance
3 — high chance
0 — would never doze
1 — slight chance
2 — moderate chance
3 — high chance
0 — would never doze
1 — slight chance
2 — moderate chance
3 — high chance
0 — would never doze
1 — slight chance
2 — moderate chance
3 — high chance
0 — would never doze
1 — slight chance
2 — moderate chance
3 — high chance
0 — would never doze
1 — slight chance
2 — moderate chance
3 — high chance
0 — would never doze
1 — slight chance
2 — moderate chance
3 — high chance
0 — would never doze
1 — slight chance
2 — moderate chance
3 — high chance
Section 7 — Mini-ACE: Memory & thinking
Because you are aged over 60, we include a short memory and thinking assessment. This is routine for all patients in this age group and helps your anaesthetist plan your care.
Please read the address below carefully. You will be asked to recall it later.
Harry Barnes 73 Orchard Close Kingsbridge Devon
What year is it?
What month is it?
What day of the week is it?
What season is it?
Write as many animals as you can think of. You have one minute. Type them separated by commas.
Animals counted:0
If completing this with help from someone, they should time you for 60 seconds.
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Section 7 continued — Mini-ACE: Recall & clock
Without looking back, please type as much of the address as you can remember.
The clock drawing task cannot be completed digitally. Your anaesthetist or nurse will ask you to draw a clock face showing 10 past 11 at your pre-operative assessment or on the day of admission.
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Review your answers
Please check your answers below. When you are happy they are correct, press Submit.
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Questionnaire submitted
Thank you. Your anaesthetist will review your answers before your procedure. You may close this page or print a copy for your records.
Anaesthetist pre-operative summary
Generated by pre-anaesthetic patient questionnaire — responses are patient self-reported and unverified.