Integrated PREAC Form (Sample)
The Royal Brisbane & Women’s Hospital
PATIENT IDENTIFICATION LABEL:
Health Service District
INTEGRATED PRE-ADMISSION
ASSESSMENT
FORM
UR No.:
___________________________________________
Name:
___________________________________________
Address:
___________________________________________
DOB: /
/
Male
Female
(or affix patient ID label here)
TO THE PATIENT:
Please fill in all the shaded areas on pages 1 & 2. Circle ‘Y’ or ‘N’ as appropriate or place a
cross in the appropriate box. You can attend your GP to assist in completion of this form is
necessary.
Do you have any religious/cultural needs?
Interpreter needed?
No
No
Yes
Home:
Yes Language spoken:
Do you have difficulties with speech, hearing, touch or vision?
Are these contact details correct?
Telephone Details:
No
No
Work:
Yes
Other:
Yes
LOCAL DOCTOR (GP):
Dr’s Name:
Telephone:
Fax:
Address:
Postcode:
REASON FOR ADMISSION/PROCEDURE
Pre-admission Date:
TCI Date:
Consultant:
Admission Time:
am
pm
DAY OF ADMISSION (Nurse): (Instructions for SDCU or WARD)
SAFETY ALERTS:
AT RISK OF FALLS?
Patient colonised/infected with multi-resistant organisms?
Medications taken?
No
No
No
Yes
Yes
Yes Patient belongings labelled?
No
Yes
QUESTIONS ABOUT YOUR GENERAL HEALTH
Past Medical History Please list any major problems with your health or surgery in the past 10 years (including any complications)
Illness or Surgery Type
Date
A)
B)
C)
D)
Do you smoke?
No
Yes
Have you ever smoked? When did you cease?
No
Yes
How many & for how long?
INTEGRATED PRE ADMISSION ASSESSMENT FORM
Procedure Date:
-2ALLERGIES:
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RELEVANT HISTORY (Medical, Surgical, Social, Family)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
CURRENT MANAGEMENT PLAN:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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Signature: ________________________ Print Name: ___________________________
Date: ____/____/____
Designation: ___________________________
Do you have or have you ever had any of the following?
1. Asthma
No
Yes
When?
2. Chronic or productive cough (bronchitis or bronchiectasis)
No
Yes
Describe duration, colour & amount:
3. Home oxygen or CPAP
No
Yes
Explain:
4. Shortness of breath or difficulty breathing (including when you are
lying flat)
No
Yes
5. High blood pressure
No
Yes
How long?
6. Chest pain, angina or heart attack
No
Yes
Which/when?
7. Heart disease, artificial valve or pacemaker
No
Yes
Which/when?
8. Rheumatic fever, heart murmur, irregular pulse or palpitations
No
Yes
When?
9. Swelling of ankles
No
Yes
10. Blood disorder (eg. leukaemia or anaemia)
No
Yes
What type/when?
11. Blood transfusion
No
Yes
When?
12. Blood clots in legs or lungs
No
Yes
Which/when?
13. Bleeding tendency or easy bruising
No
Yes
When?
14. Diabetes
No
Yes
How is it controlled?
15. Hepatitis, jaundice or cirrhosis
No
Yes
What type/when?
16. Kidney disorder
No
Yes
What type/when?
17. Gastric reflux, hiatus hernia or heartburn
No
Yes
Which/when?
18. Epilepsy or other fits
No
Yes
When?
19. Stroke
No
Yes
What is affected?
20. Organ transplant
No
Yes
Which/when?
21. Do you have an artificial joint, hearing aid, contact lenses
No
Yes
Please specify:
22. Significant neck or back injury
No
Yes
Explain:
23. Other serious illness or disabling condition
No
Yes
What/when?
24. Was your last menstrual period more than 3 weeks ago?
No
Yes
How many weeks?
25. Are you currently breast feeding?
No
Yes
26. Do you suffer from anxiety, depression or emotional disorders?
No
Yes
27. Do you drink alcohol?
No
Yes
How much a day?
28. Do you have any allergies (drugs/food/tapes)?
No
Yes
To what?
When?
CURRENT MEDICATIONS TAKEN: Regular & prn. Include ALL medications including over the counter
medications, inhalers, topical, eyedrops & painkillers. Please bring them to hospital with you.
Name
A)
B)
C)
D)
E)
Strength
How many tablets per day? (number at each time)
YOUR ANAESTHETIC HISTORY (This point forward to be completed by Hospital Staff Only)
30. Have you had a cough/cold/sore throat in the past
fortnight?
No
Yes
31. Have you had any problems with anaesthetics or surgery
before (eg. nausea, temperature, and prolonged drowsiness)?
No
Yes
32. Do you have any blood relatives who have had problems
with anaesthetics?
No
Yes
33. Do you have any capped, false or loose teeth?
No
Yes
34. Is there any limitation in the movement of your neck or
jaw? (you should be able to open your mouth at least 2 finger
widths & be able to tilt your head to look straight up)
No
Yes
35. Does any condition prevent you from undertaking normal
daily activities?
No
Yes
36. Do you have any other chronic pain conditions?
No
Yes
37. Tick the box most applicable to you
Comments:
Give details:
Give details:
Give details:
Give details:
What/when?
Give details:
A) No limitation to activity
B) Slight limitation to activity, can walk one flight of
stairs without resting
C) Marked limitation of normal activity, cannot walk one
flight of stairs without resting
D) Pain or short of breath at rest
38. Do you have any questions or concerns about the
anaesthetic, operation or coming into hospital you
would like to discuss?
No
Yes
ANAESTHETIC REFERRAL BY NURSE
Day Surgery
Day of Surgery Adm.
Refer to Anaesthetist
Surgery deferred
Reason / Management:
PHYSIOTHERAPY ASSESSMENT (if required)
Medical & nursing assessment noted Other notes/alerts:
Auscultation:
Muscle power/ROM:
Other specific tests/findings:
Exercise tolerance:
History DVT/PE
Instructions given:
TED - Size:
SEQUENTIAL COMPRESSION - Size:
Deep breathing
Supported Huff
Circulation Exercises
Specific Instructions:
Physiotherapist Name:
Signature:
Date:
PLANNING FOR YOUR CARE (refer to nursing guidelines if answer is Yes)
Accommodation
House/Unit
Number of stairs/steps
Nursing Home
Hostel
Front/back:
Retirement Village
Internal:
A) Will the patient’s occupation affect their recovery?
No
Yes
B) Will you be by yourself at home when you leave hospital?
No
Yes
C) Do you have dependants living with you?
No
Yes
C) If you have dependants, do you have any problems making
arrangements to care for them?
No
Yes
D) Do you receive any community support services such as domiciliary
nursing, home help, and meals on wheels or ambulance?
No
Yes
E) Do you have any difficulty managing day to day activities such as
stairs, bathing, dressing, going to the toilet or performing home duties?
No
Yes
F) Have you had any falls in the last few months?
No
Yes
F) Do you use a walking aid such as a stick or frame?
No
Yes
G) Do you have any swallowing/eating difficulties or special dietary
needs?
No
Yes
G) Have you had a recent change in your weight?
No
Yes
H) Have you any problems with passing urine or with your bowels?
No
Yes
I) Have any communication difficulties been identified?
No
Yes
J) Have any chronic conditions been identified?
No
Yes
Weight:
OBSERVATIONS (guidelines 39 – 42)
B/P:
Temp:
Boarding
Resps:
Height:
Which?
Which?
BMI:
Pulse:
Oxygen Saturation:
K) Skin/Integument: does the patient have any wounds,
ulcers, cuts bruises or other problems?
Circle affected areas and describe:
Pressure area risk score:
PRE-ADMISSION PLAN
No
Discharge problems identified?
Yes
Education sheet discussed with patient
Patient care plan completed?
No
Yes
Post op pain education performed
Vital signs recorded
Nursing assessment completed by:
Nurse’s name:
Patient’s signature:
Signature/designation:
Date:
Expected Discharge Date: