Online Booking – Ryde Public Hospital

Complete this online form to book a procedure at Ryde Public Hospital. It takes between 15-20 minutes to complete all 20 categories.
Please answer all questions (if not applicable or unknown simply type “NA” in the text box).

1. PERSONAL DETAILS

Title

Family Name

Given Name

Middle Name

Preferred Name

Maiden Name

Mother's Given Name

Mother's Family Name

Father's Given Name

Father's Family Name

Sex

DOB

----

Do you have a valid medicare number?

Medicare Number:

(if not applicable type "NA")

Medicare Reference Number

Expiry Date:

(if not applicable type "NA")

---

Do you have a Pension Card?

 yes no

Do you have a Centrelink Health Care Card?

 yes no

Pension or Centrelink Card Number:

(if not applicable type "NA")

----

Do you have a private health insurance?

 yes no

Health Fund:

Health Fund Membership Number:

(if not applicable type "NA")

Type of room requested (if Private Health Insurance):

Level of cover (if Private Health Insurance):

Do you choose to be self-funded private patient ?(if no private health insurance)

 yes no

Is your health covered by Veterans Affairs?

 yes no

DVA Card Number:

(if not applicable type "NA")

DVA Card Colour:

---

Marital Status

---

Are you Aboriginal of Torres Strait Islander Origin?

2. PERMANENT ADDRESS

Buliding/Property Name and Street Address

Suburb/Town

State

Home Phone Number

Mobile Phone Number

Work Phone Number

3. POSTAL/TEMPORARY ADDRESS (inc overseas/country visitors)

Buliding/Property Name and Street Address

Suburb/Town

State

Home Phone Number

Mobile Phone Number

4. EMERGENCY CONTACT

Relationship to patient

Family Name

Given Name

Address

Home Phone

Mobile

5. PERSON RESPONSIBLE

Relationship to patient

Family Name

Given Name

Address

Home Phone

Mobile

6. CARER CONTACT DETAILS

Do you have a carer ?

 yes no

Do you consent them giving/receiving information form medical staff?

 yes no not applicable

Carer's relationship to the patient

Is the Carer Paid or Unpaid?

Carers Family Name

Carers Given Name

Carers Address

Carers Home Phone

Carers other phone

7. GENERAL PRACTITIONAR/MEDICAL CENTRE

Name

Name of Surgery/Practice:

Street Address

Suburb/Town

Phone

Phone

8. CONSENT

Release of Information

Please be aware that your nominated local doctor/specialist/other healthcare provider/carer will be advised of your admission and may be provided with details of any investigations, treatments and other medical care provided to you during your admission. This information will be shared to assist in your ongoing care under the Health Records and Information Privacy Act 2002.
NOTE: If you do not wish for us to collect certain information about you, you need to tell us and we will discuss with you any consequences this may have for your health care.

Leaving the Hospital

I understand that if I am discharged on the same day as anaesthetic/sedation and my surgery/procedure, I should not drive a motor vehicle or drink alcohol for 24 hours. I also understand that I must be accompanied home and cared for by a responsible adult for 24 hours.

Do you agree to the terms and conditions outline above?

 yes no

9. ANAESTHETIC ASSESSMENT

Do you have any allergies?(especially to food, medications, sticking plaster, iodine or latex?)

 yes no

What are you allergic to?:

Have you or any of your blood relatives had any problems with an anaesthetic? (including dentist):

 yes no

Do you have any difficulty with neck movements, or opening you mouth wide?:

 yes no

Medications: Please list your regular medications below. Include prescribed and non prescribed medications eg. Aspirin, alternative medicines eg. vitamins and herbal medicine, puffers, eye drops and creams:

10. CARDIOVASCULAR

Do you have or have you ever had any of the following?:

High blood pressure

 yes no

Chest pain or angina

 yes no

Heart attack

 yes no

Pacemaker, irregular heart beat or any other heart condition

 yes no

Have you ever had a heart test? eg. stress test, or ultrasound

 yes no

Have you ever seen a cardiologist

 yes no

If you have answered yes to any of the above questions, please give full details below:

11. RESPIRATORY

Do you have or have you ever had any of the following?

Can you normally walk without stopping:

More than two flights of stairs

 yes no

One flight of stairs (eg. 10 steps)

 yes no

Half a flight of stairs

 yes no

Around the house

 yes no

Shortness of breath when lying flat?

 yes no

Are you being treated or have you been investigated for sleep apnoea?

 yes no

Chronic bronchitis/emphysema

 yes no

Do you suffer from asthma?

 yes no

Have you had tuberculosis?

 yes no

Have you ever seen a respiratory (lung/breathing) specialist?

 yes no

If you have answered yes to any of the above questions, please give full details below:

12. ENDOCRINE

Do you have or have you ever had any of the following?:

Diabetes?

 yes no

Thyroid problems

 yes no

Have you ever seen an Endocrinologist (Diabetes) specialist doctor for your diabetes or thyroid problems?

 yes no

If you have answered yes to any of the above questions, please give full details below:

13. NEUROLOGY

Do you have or have you ever had any of the following?

Epilepsy of fits?

 yes no

Stroke/mini stroke?

 yes no

Past history of delirium or been confused when you have been ill or in hospital in the past?

 yes no

Blackout, fainting or falls?

 yes no

Have you ever seen a Neurologist (nervous system)?

 yes no

If you have answered yes to any of the above questions, please give full details below:

14. BLOOD CONDITIONS

Do you have or have you ever had any of the following?

Blood clots or bleeding - self or relatives?

 yes no

Anaemia?

 yes no

Previous blood transfusion?

 yes no

Known antibodies in your blood?

 yes no

Have you ever seen a haematologist (blood)?

 yes no

If you have answered yes to any of the above questions, please give full details below:

15. GASTROINTESTINAL

Do you have or have you ever had any of the following?

Stomach Ulcers/Hiatus Hernia/Reflux?

 yes no

Hepatitis or liver condition?

 yes no

If you have answered yes to any of the above questions, please give full details below:

16. RENAL

Do you have or have you ever had any of the following?

Renal (Kidney) problems?

 yes no

Have you ever seen a renal specialist?

 yes no

Do you, or any blood relatives have any serious inherited disease? Eg. malignant hypothermia, muscular dystrophy, thalassemia??

 yes no

If you have answered yes to any of the above questions, please give full details below:

17. PAST SURGERY

Do you have or have you ever had any of the following?

Have you ever had previous surgery, transplant or interventional procedure?

 yes no

Have you ever been advised during a hospital admission that you have had a multiple-resistant organism eg. MRSA, VRE, Clostridium difficile?

 yes no

If you have answered yes to any of the above questions, please give full details below including dates and hospitals:

18. GENERAL/SOCIAL

Do you have or have you ever had any of the following?

Could you be pregnant, or pregnant in the last three months??

 yes no

Do you have any speech, hearing, vision or swallowing disability or problems?

 yes no

Are you on a special diet?

 yes no

Do you smoke?

 yes no

Are you an ex-smoker?

 yes no

How many cigarettes a day do you smoke?

Do you drink alcohol?

 yes no

How often do you drink alcohol?

How many standard drinks do you have a day?

Do you take recreational drugs?

 yes no

Do you live on your own?

 yes no

If you have answered yes to any of the above questions, please give full details below including dates and hospitals:

19. DISCHARGE PLANNING

Do you have or have you ever had any of the following?

Do you have someone to collect you from the hospital? (The hospital can not provide transport home. Morning discharges should be by 10am. Day only patients having an anaesthetic must have a responsible adult to accompany you home and stay with you at least for the first night)

 yes no

Do you have someone who can care for you following your procedure/surgery if needed?

 yes no

Do you receive community services?

 yes no

Do you expect any difficulties looking after yourself at home following discharge from hospital?

 yes no

Do you have a carer? (A carer is anyone who gives regular assistance to ie. husband, wife, child and friend, neighbor):

 yes no

Does someone close to you rely on you for care?

 yes no

Have you arranged for alternative care for that person while you are in hospital?

 yes no

Do you require an aid for walking ?

 yes no

Please specify your level of mobility

Are you available to go on a standby/short notice list for this procedure (this will be subject to clinic review)?

 yes no

Any other health issues or disabilities you wish to mention?

 yes no

If you have answered yes to any of the above questions, please give full details below including dates and hospitals:

20. OTHER

Please complete patient details in this section:

Height (approximate if unknown) in cm:

Weight (approximate if unknown) in kg:

Who has completed this questionnaire? (patient or other? Please state their relationship) :

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