WRHA Surgery Program
PREoperative
Assessment Patient
Questionnaire
July 2010
Carol Knudson
WRHA Perioperative Nurse Educator
Preamble
• Questionnaire development was a collaborative
effort by the WRHA Surgery Program and PAC
• Facilitates the collection of consistent patient
information across surgical sites within the region.
• Promotes patient safety, enhances quality of patient
care and service delivery to the patient population
we serve.
• NOTE: Replaces the Patient/Nursing database for
the elective surgery patient population.
Purpose
• Collect information from patients
coming for elective surgery.
• Information from questionnaire will
be reviewed by PAC nurse to
determine if additional information,
assessments or testing is required
prior to surgery.
General Information
• To be completed by ALL surgical
patients (including Day Surgery
Patients) scheduled for Elective
surgery EXCEPT: orthopedic
total joint hip and knee
arthroplasty.
• To be completed and MAILED or
DROPPED OFF at the surgeon’s
office AT LEAST THREE (3)
WEEKS PRIOR to the surgery
date.
• Will be included in the PAC
package and is intended to be
circulated to the patient by the
surgeon/office.
• Completed questionnaire
required in order to slate the
surgical procedure.
• Right side intended for
documentation by the nurse and is
for “Hospital Use Only”
• Completed questionnaire is dated,
signed and placed in the patient
health record and becomes part of
the permanent health record.
Patient to Indicate
• Personal Health Information Number (PHIN)
• Legal Name (as found on Provincial Health
Card)
• Preferred Name
• Date of Surgery (DD/MMM/YYYY)
• Surgeon’s Name
• Type of Surgery
• Health Care Directive (copy attached)
• Information related to language spoken and
understood
• Contact person including relationship and
phone #
• Name of person picking up from hospital on
discharge including relationship and
phone# (required for patients receiving
general Anesthetic or Conscious Sedation)
• Indication of hospitalization in the past
six(6) months for
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MRSA
VRE
TB/Alert
C-diff
Other
• Allergies or sensitivities
• Medic Alert® Bracelet including reason for
wearing
• Medications including prescription
drugs, over-the-counter drugs, herbs,
or other
• If coming to PREoperative
Assessment Clinic, patient to bring
containers of all prescription and
over the counter medications
• Family Doctor’s name, phone number,
date, and reason for last visit
• Specialist Doctor’s name, phone
number, date, and reason for last
visit
• Possibility of pregnancy
• Height and Weight
• Obstructive Sleep Apnea (OSA) Risk
questions replacing OSA Risk Identification
and Risk Assessment in Perioperative
adults form #W-00255
 Patients to indicate “yes”/“no” to the following:
 Do you have OSA?
 Have you been told that you have OSA?
 Do you snore loudly (loud enough to be heard
through closed doors?)
 Do you think you have abnormal or excessive
sleepiness during the day?
 Has anyone noticed that you momentarily stop
breathing during your sleep?
 Is your neck measurement greater than 40cm?
• Shortness of breath or tightness
in the chest if
Lying flat in bed
Walking 1 block
Climbing 1 flight of stairs
Housework, getting dressed
• Health History
including:
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Chest pain
Angina
Heart attack
CHF
Heart murmur
Fast/skipped heart
beat
Rheumatic fever
High Blood Pressure
Diabetes
Persistent swelling
in feet of legs
Lung problems
SOB, cough, wheeze
OSA
Home oxygen
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CPAP/BiPAP machine
Stroke
TIA/mini-stroke
Migraine/headache
Blackouts/fainting
spells in past year
Seizures
Recent memory loss
Disease of nervous
system
Parkinson’s disease
Muscle disease
Joint/bone problems
Chronic pain
Falls within 6
months
Gout
Frequent heart burn
Ulcers
 Hepatitis/jaundice/liver
disease
 Bowel disease
 Kidney/bladder
problems
 Hemodialysis
 Peritoneal dialysis
 Cancer
 HIV/AIDS
 Anemia/Low Iron
 Blood Transfusion
 Bleeding Problems
 Sickle Cell Disease
 Blood Clots (legs,
lungs, pelvis)
Glaucoma
Thyroid Problems
Mental Health Issues
Dementia
Depression
Anxiety/Panic Attacks
Malignant Hyperthermia
Pseudocholinesterase
Deficiency
 Implanted Electronic
Devices
 Other
 Health Problems that run
in family
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• Received or had problems with anesthetic
• Family member had problem with
anesthetic
• Previous surgeries including date and
hospital
• Admission to hospital for reasons other
than surgery including date, reason for
admission and hospital
• Special tests including name of the test,
date, and hospital
 Examples include Stress Test, Ultrasound, and
angiogram
• Transfusion History including
 rare blood type
 objection to receipt of transfusion
 previous transfusions indicating any problems
• Smoking History including
 amount smoked per day
 number of years smoked
 when quit (if applicable)
• Alcohol consumption including amount and
how often
• Use of recreational drugs including amount
and how often
• Having any of the following:
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Capped or Loose Teeth
Contact Lenses
Eyeglasses
Dentures
Hearing Aid
Body Piercings
Other (examples artificial limbs or artificial eye)
• Nutritional Status including:
 Type of diet
 Difficulty eating or swallowing
 Weight gain, loss including amount and over what
time period
 Nausea, vomiting, choking, indigestion, reflux,
anorexia
• Elimination Pattern including
 Ostomy
 Urinary pattern (urgency, incontinence,
frequency, nocturia
 Bowel pattern (diarrhea, constipation,
incontinence
 Other (example catheter)
• Functional status with explanations
including:
 Changes in activities of daily living
 Assistance required for toileting,
bathing, dressing, walking
 Use of crutches, cane, walker,
wheelchair, scooter, mechanical lifts,
bathroom assists
 Any changes to sleep pattern
 Pain including description of intensity
• Living arrangements including:
Lives alone, with spouse/partner,
child(ren), pets, other
Lives in an apartment, house,
group home, PCH, supportive
housing, assisted living
Use of stairs including number and
whether railings present
• Use of community services including:
 Home Care
 Dietitian
 Handi-transit
 Physiotherapy
 Day Hospital
 Occupational Therapy
 Lifeline®
 Treaty Number and Band Name
 Social Assistance including case#, case
worker name and phone#.
• Difficulties related to hospitalization
including an explanation:
 At home
 At work
 With finances
 Other
• Date and name of person completing
questionnaire
Nurse completes section
Hospital Use Only
• Completed based on information gathered
during patient assessment
• Patient vital signs:
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Temperature
Pulse
Respiratory Rate
Blood Pressure – indicate left or right arm
O2 SATS
• Indicate that Medication Reconciliation
completed
• Indicate Height (cm) and Weight (kg)
• Calculate BMI (refer to chart or calculate
as Weight in kg/Height in m2
• Determine patient risk of OSA based on
response to OSA questions and reference
to laminated poster “Guidelines: OSA
Interpretation of Risk Score
 Known OSA (PAC referral required)
 High Clinical Suspicion (PAC referral required)
 Low Clinical Suspicion
• Indicate if consults have been initiated and
if so where
• Indicate if Risk for Falls Protocol
• Indicate any other pertinent information
gathered from the patient during the
assessment in the space allotted
What happens with
questionnaire once returned to
surgeon office?
• Surgeon’s office forwards
Questionnaire, Booking Request
Form, HX & PX, all completed tests
and Consent Form to PAC.
• Complete package is triaged by
clinicians
• Patient is contacted by phone if
clarification is required
• PAC books clinic appointments and notifies
patient of same (if applicable)
• At clinic appointment, nurse documents
any additional information on the right-hand
side of the questionnaire.
• Nurse required to sign and date
questionnaire. NOTE: Questionnaire is part
of the patient’s health record.