Online Booking – Westmead Private Hospital

Complete this online form to book a procedure at Westmead Private Hospsital. It takes between 8-20 minutes to complete all 33 categories.
Please answer all questions (if not applicable or unknown simply type “NA” in the text box).

1. ADMISSION DETAILS

Admitting Specialist*

Length of Stay

Do you know your admission date?

 yes no

Date of Admission:

(if not known type "NA")

Procedure/Reason for Admission:*

2. DETAILS OF PERSON COMPLETING FORM

Person completing Form:

Relationship to Patient

3. PATIENT DETAILS

Title

Surname

Given Names

DOB

Sex

Marital Status

Address

Home Phone Number

Business Phone Number

Mobile Phone Number

Allow SMS alert?

 yes no

Employment

Are you Aboriginal/Torres Strait Islander (TSI) descendent?

Are you of Australian South Sea Islander(SSI) descent?

Religion

Do you consent to the Hospital disclosing your personal information to the visiting Chaplain?

 yes no

Do you consent to the Hospital disclosing your personal information to the Veteran Organisation Representative?

 yes no

Language spoken at home:

Interpreter required?

 yes no

4. CONTACT PREFERENCES

Indicate your preferred contact options

5. GENERAL PRACTITIONER (GP) DETAILS

Referring GP

GP address

GP Phone No:

6. NEXT OF KIN

Title

Surname

Given Names:

Telephone (Wk/Day)

Telephone (Home/AH)

Mobile/Other Phone Number

7. PERSON TO NOTIFY

Title

Surname

Given Names:

Telephone (Wk/Day)

Telephone (Home/AH)

Mobile/Other Phone Number

8. ENDURING POWER OF ATTORNEY

Do you have a current Advance Health Directive?

 yes no

Do you have enduring power of attorney - health and medical guardian?

 yes no

Name, Relationship and Contact Phone Number of guardian:

(if not applicable type "NA")

9. PERSON RESPONSIBLE FOR PAYMENT OF ACCOUNT

Person responsible for payment of account?

10. MEDICARE DETAILS

Do you have a valid medicare number?

Medicare Number:

(if not applicable type "NA")

Medicare Reference Number

11. PENSIONS/CONCESSIONS/HEALTH CARE CARD/SENIORS CARD/CONCESSIONAL PHARMACY BENEFITS

Do you have a Health Care Card?

 yes no

Do you have a Pension Card?

 yes no

Do you have a Pharmaceutical Benefits Card?

 yes no

12. HEALTH INSURANCE DETAILS

Insurance Type:

Health Fund:

Health Fund Membership Number:

(if not applicable type "NA")

Have you changed your level of insurance cover in the last 12 months?

 yes no

Worker's Compensation Claim Fund Name, Policy Number & Claims Officer contact number:

(if not applicable type "NA")

13. ADMISSION INFORMATION

Is your admission to hospital for treatment of an injury?

Could you be pregnant?

 yes no

Have you had x-rays taken for this admission?

 yes no

Have you had bloods taken for this admission?

 yes no

Have you donated your own blood for the purposes of this operation/

 yes no

Have any other doctors been consulted recently e.g. cardiologist, physician? If yes, please write details below:

(if not applicable type "NA")

14. PREVIOUS HOSPITALISATIONS

Have you been admitted to this hospital before?

 yes no

Have you been admitted to any hospital in the last 7 days?

 yes no

Have you been admitted to any hospital in the last 28 days?

 yes no

15. PREVIOUS SURGERY/PROCEDURES eg joint replacement, transplants, implants, colonoscopy

Previous Operations (state also the surgeon and year of surgery):

16. MEDICATIONS

Do you take anti-coagulant or blood thinning therapy (Warfarin, Coumadin, Plavix, Iscover, Aspirin, Pradaxa)

Do you take steroids, anit-inflammatory durgs, contisone tablets/injections

 yes no

Do you take herbal supplements or complementary therapies eg. fish?oil

 yes no

Have you received advice from your specialist rooms regarding taking/ceasing your medications prior to admission?

 yes no

Current Medications, dose and frequency:

(if not applicable type "NA")

17. ALLERGIES / ALERTS

Do you have adverse reactions to anaesthetics e.g malignant hyperthermia?

 yes no

Do you have a family member with an adverse reaction to anaesthetic?

 yes no

Do you have foods excluded from your diet?

 yes no

Do you have allergies to medications, food, sticking plaster, later / rubber (e.g. balloons, gloves) or other substances?

 yes no

Do you have a medical dietary restriction? (e.g. diabetic, Coeliac Disease, Lactose Intolerance)?

 yes no

Do you require a special diet? (e.g. Vegetarian, Vegan, Kosher etc)

Allergies Including Food Allergies:

(if not applicable type "NA")

18. LIFESTYLE

Height (cms):

Weight (kg):

Have you recently lost weight unintentionally?

 yes no

Have you ever smoked?

 yes no

Do you drink alcohol?

 yes no

Do you use recreational drugs?

 yes no

Do you exercise regularly eg 3 times per week?

 yes no

Do you have chronic pain?

 yes no

19. CARDIOVASCULAR

Elevated cholesterol, triglycerides?

 yes no

Blood pressure problems eg. low, hypertension

 yes no

Cardiac conditions eg. heart attack, congestive heart failure, rheumatic fever, valve disease, chest pain, angina

 yes no

Vascular disease eg. carotid disease, aortic aneurysm, peripheral vascular disease.

 yes no

Family history of cardiac disease

 yes no

20. ENDOCRINOLOGY

Diabetes

 yes no

Blood glucose levels normal greater than 10mmol:

 yes no

Thyroid problems, hypothyroidism, goiter

 yes no

21. GASTROINTESTINAL

Hiatus hernia, gastrointestinal ulcers, reflux

 yes no

Liver disease, hepatitis (eg. A, B, C), jaundice:

 yes no

Bowel problems/habits, stoma or bowel disease eg. Crohns, IBS:

 yes no

22. GENTIOURINARY

Kidney disease, dialysis, renal impairment:

 yes no

Bladder problems or habits, stoma, incontinence, urinary retention:

 yes no

23. HAEMATOLOGY & ONCOLOGY

Ever had a blood transfusion?

 yes no

Blood Type:

(if unsure type "unknown")

Diagnosed with cancer:

 yes no

Blood clot in lungs / legs (DVT / PE):

 yes no

Blood disorder eg. anaemia

 yes no

Bleeding disorders or problems:

 yes no

24. MUSCULOSKELETAL

Arthritis eg. rheumatoid arthritis, osteoarthritis:

 yes no

Back or neck injury or problems:

 yes no

25. NEUROLOGY

Neuromuscular diseases eg. MS, myasthenia, dystrophies, parkinsons

 yes no

Stroke, mini stroke, TIA:

 yes no

Speech problems or swallowing problems eg coughing when eating or drinking:

 yes no

Limb paralysis or weakness:

 yes no

Difficulties with attention span, understanding and/or problem solving:

 yes no

Epilepsy, fits, blackouts, funny turns:

 yes no

Other neurological problems eg. migraine, polio, meningitis:

 yes no

Short term memory loss or dementia?

 yes no

Previous confusion in hospital

 yes no

26. PROSTHETICS / AIDS / OTHERY

Visual aids eg. glasses, contact lenses, visual impairment

Hearing aids, hearing appliance or hearing impairment, cochlear implant

Dentures, caps, crowns, loose teeth, implants, veneers

Other aids for daily living - eg. artificial limbs:

 yes no

27. RESPIRATORY

Asthma, Pneumonia, Hay Fever, Asbestosis, Chronic Obstructive \Pulmonary disease (COPD) eg. bronchitis, emphysema:

 yes no

Shortness of breath eg. walking more than 50m, climbing stairs/inclines

 yes no

Sleep apnoea, disturbed sleep, snoring:

 yes no

Do you use a CPAP machine?

 yes no

Other lung problems eg. tuberculosis:

 yes no

28. OTHER

Depression, other mental illness:

Lymphoedema

 yes no

29. FALLS RISK

Do you have a fear of falling, are unsteady on feet or have fallen in last 6 months?

 yes no

Do you use mobility aids eg walking stick, frame etc?

 yes no

Have you experienced fainting, dizziness in last 6 months?

 yes no

30. INFECTION RISK

Have you travelled to a country with a health alert in the last 7 days?

 yes no

Do you have a fever and/or respiratory symptoms eg. cough, sore throat, runny nose?

 yes no

Have you had recent contact with patient/s diagnoses with Acute Respiratory Infections or Acute Respiratory Illness in the last 7 days (Seasonal or Pandemic) eg. SARs/H5N1 Influenza 09, either oversease or in Australia, within 7 days of onset of symptoms?

 yes no

Have you travelled to areas of high prevalence for Acute Respiratory Infections or Acute Respiratory Illness in the last 7 days (Seasonal or Pandemic) eg. SARs/H5N1 Influenza 09, either oversease or in Australia, within 7 days of onset of symptoms?

 yes no

Have you ever had MRSA, VRE or ESBL?

 yes no

Do you have any wounds or breaks on your skin?

 yes no

Do you have any other conditions or infections?

 yes no

Have you had vomiting & diarrhoea in the past 48 hours

 yes no

Are you having an operation on your: brain, pituitary gland, spinal cord, nerve root ganglia, retina, optic nerve or having facial maxillary surgery?. If you are unsure please tick YES.

 yes no

31. cCJD

1. Do you think you may have cCJD?

 yes no

2. Do you have a first degree relative with cCJD?

 yes no

3. Have you an unexplained progressive neurological illness of less than 12 months?

 yes no

4. Have you a history of receiving human pituitary hormone for infertility or human grown hormone for short stature (prior to 1986)?

 yes no

5.Have you previously had brain or spinal cord surgery that included a dura mater graft (prior to 1990)?

 yes no

6. Have you been involved in a look back for cCJD or have a "medical-in-confidence" letter regarding your risk for cCJD?

 yes no

32. DISCHARGE PLANNING

Do you live alone?

 yes no

Do you have someone to look after your after discharge?

 yes no

Who will look after you after discharge? Please provide name, relationship and contact phone number:

(if not applicable type "NA")

Do you currently receive community support and/or nursing services?

 yes no

Do you require assistance or have any concerns with any aspects of day to day living?

 yes no

Where do you plan to go after discharge?

Will there be someone to look after you after discharge?

 yes no

Do you have escorted transport from hospital?

 yes no

33. ADDITIONAL COMMENTS

If you would like to make any additional comments please do so below:

(if not applicable type "NA")

captcha
Please type the letters and numbers above.