Patient Admission Form 1Personal and Admission Details2Patient Health Questionnaire3Patient Health Questionnaire 24Review and Submit5 PERSONAL AND ADMINISTRATION DETAILSTitle(Required)MrMrsMsMissMstrDrSurname (Family Name)(Required) First Name (s)(Required) Preferred Name Date of birth(Required) DD slash MM slash YYYY Sex at birth(Required) Male Female Gender(Required) Male Female Gender diverse Nonbinary Other Specify gender NHI Residential Address(Required) Street Address Address Line 2 City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Use different address for postal address Yes Postal Address Street Address Address Line 2 City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email address(Required) Telephone: (Home)BusinessMobile(Required)New Zealand resident Yes No Ethnicity(Required)AfricanAsianChineseCook Island MāoriFijianIndianLatin American / HispanicMiddle EasternNiueanNZ EuropeanNZ MāoriOther AsianEuropeanPacificSamoanSouth East AsianTokelauanTonganGeneral Practitioner (Name) TelephoneMedical Centre:(Required) NEXT OF KIN/CONTACT PERSONName(Required) Relationship to patient(Required) Address Telephone: (Home)BusinessMobile(Required)PAYMENT DETAILSHow will your procedure be paid for? Tick and complete all that apply. Health insurance (personal expenses)Name of Insurer Insurance Plan Name Have you obtained 'prior approval' for payment? Yes No Approval No: Bring your prior approval letterACC (personal expenses such as telephone calls are excluded) DHB (some personal expenses are excluded) Paid personally. If you are paying for the procedure yourself, you may be asked to pay an estimated deposit 3-5 days before admission. The balance of your account must be settled on discharge.I will pay my account by EFTPOS Credit Card Debit Card Internet Banking Cheque For internet banking Payee: Ormiston Surgical and Endoscopy Limitied Particulars: Patient Name Bank a/c 02-0191-522222-000 Reference: Invoice Number AGREEMENTI agree to settle my Hospital account I give…. I give… I understand…Name(Required) Date(Required) DD slash MM slash YYYY Please complete this questionnaire carefully as the information you supply helps us to provide you with the best and safest possible care during your stay at our hospital. The questionnaire has four sections: A. Your general health B. In preparation for your hospital admission C. In preparation for your procedure D. Your current medicines Surname (family name)(Required) First name (s)(Required) All questions in this questionnaire are about the person being treated at the hospital (the patient). If you are filling this out for the patient, only provide information related to the patient’s health.Weight(Required)kilogramsHeight(Required)metresSurgeon NHI (if known)Occupation (optional)SECTION A. YOUR GENERAL HEALTHA1. MEDICAL PROCEDURE HEALTH ALERTSDo any of the following apply to you?1. Difficulty climbing more than a flight of stairs:(Required) Yes No (If yes) What restricts this activity? 2. Motion sickness:(Required) Yes No (If yes) Mild | Moderate | Severe 3. Jaw problems (difficulty opening mouth):(Required) Yes No (If yes) Specify 4. Problems with a previous anaesthetic:(Required) Yes No (If yes) Specify 5. Family history of problems with an anaesthetic:(Required) Yes No (If yes) Specify 6. Pacemaker or heart valve replacement:(Required) Yes No (If yes) Specify name of cardiologist 7. Joint implants:(Required) Yes No (If yes) Specify 8. Other implants or prothesis:(Required) Yes No (If yes) Specify 9. Substance use or dependency:(Required) Yes No (If yes) Specify substance Specify what and how often to you use it10. Former smoker:(Required) Yes No (If yes) When did you quit? 12. Current smoker:(Required) Yes No (If yes) Specify how many per day 11. Currently on smoking cessation treatment:(Required) Yes No (If yes) Specify 13. Pregnant or possibly pregnant:(Required) Yes No (If yes) Approximate due date: 14. MedicAlert bracelet or necklace wearer:(Required) Yes No (If yes) Specify A2. YOUR MEDICAL CONDITIONSDo you currently have, or have you previously had, any of the following conditions? If Yes, please pick any applicable options and provide comments in the box below.15. Breathing conditions:(Required) Yes No asthma | wheeziness | shortness of breath | bronchitis | croup | emphysema | COPDPlease specify / additional information 16. Sleeping conditions:(Required) Yes No sleeplessness | severe snoring | obstructive sleep apnoea | CPAP usedPlease specify / additional information 17. Heart conditions:(Required) Yes No palpitations | irregular heart beat | heart murmur | angina | heart attack | chest pain congestive heart failure | rheumatic feverPlease specify / additional information / specify name of cardiology 18. Stroke or Transient Ischaemic Attack (TIA)(Required) Yes No Please specify / additional information 19. High blood pressure or blood pressure controlled with medication:(Required) Yes No Please specify / additional information 20. Blood clots:(Required) Yes No Deep vein thrombosis (DVT) | pulmonary embolus (PE)Please specify / additional information 21. Family history of blood clots:(Required) Yes No Please specify / additional information 22. Blood or bleeding conditions:(Required) Yes No anaemia | bruisingPlease specify / additional information 23. Family history of blood or bleeding conditions:(Required) Yes No Please specify / additional information 24. Stomach and digestive conditions:(Required) Yes No indigestion | hearburn | acid reflux | hiatus hernia peptic ulcerPlease specify / additional information 25. Bowel conditions:(Required) Yes No irritable bowel syndrome | constipation | bowel diseasePlease specify / additional information 26. Liver disease:(Required) Yes No jaundice | hepatitisPlease specify / additional information 27. Kidney conditions:(Required) Yes No Please specify / additional information 28. Diabetes:(Required) Yes No requiring insulin | requiring tablets | diet controlledPlease specify / additional information 29. Thyroid conditions:(Required) Yes No Please specify / additional information 30. Parkinson's disease:(Required) Yes No Please specify / additional information 31. Epilepsy, seizures, blackouts or fainting:(Required) Yes No Please specify / additional information 32. Migraines or severe headaches:(Required) Yes No Please specify / additional information 33. Alzheimer's or dementia:(Required) Yes No Please specify / additional information 34. Mental function conditions:(Required) Yes No head injury | concussion | confusion or disorientationPlease specify / additional information 35. Mental health conditions:(Required) Yes No Please specify / additional information 36. Emotional conditions:(Required) Yes No anxiety | phobia | post traumatic stress disorder (PTSD)Please specify / additional information 37. Arthritis:(Required) Yes No Please specify / additional information 38. Neck or back conditions:(Required) Yes No Please specify / additional information 39. Gum or dental health conditions:(Required) Yes No Please specify / additional information 40. Tuberculosis (TB):(Required) Yes No Please specify / additional information 41. HIV or AIDS:(Required) Yes No Please specify / additional information 42. Infection or treatment for resistant organisms:(Required) Yes No MRSA | ESBL | VRE | OTHERPlease specify / additional information 43. Cancer:(Required) Yes No If Yes, please specify and provide details of any recent treatment in the comments box.Please specify / additional information 44. Other condition(s) not listed above:(Required) Yes No If yes, please specify in the comments box.Please specify / additional information SECTION B: IN PREPARATION FOR YOUR HOSPITAL ADMISSIONB1. YOUR ALLERGIES, SENSITIVITIES, OR INTOLERANCES45. Are you allergic to latex?(Required) Yes No 46. Do you have any other allergies, sensitivities or intolerances?(Required) Yes No If yes, please specify and describe the reaction.Skin-relatedItemReaction Add Remove(E.g. Plasters -> Rash)Medicine-relatedItemReaction Add RemoveFood-relatedItemReaction Add RemoveOtherItemReaction Add RemoveB2. YOUR NEEDS AND PREFERENCESPlease answer these questions to help us to tailor how we care for you. If you answer ‘yes’ to any of these questions, we may contact you to discuss your specific needs.47. Do you have a disability? Yes No (If yes) Specify 48. Do you have a difficulty understanding English? Yes No (If yes) Your preferred language Do you need an interpreter? Yes 49. Do you have any religious or spiritual needs you would like us to know about? Yes No (If yes) Specify 50. Do you have any cultural or family needs you would like us to know about? Yes No (If yes) Specify 51. Do you have any other special needs you would like us to know about? Yes No (If yes) Specify 52. If your procedure requires the removal of body parts, would you like them returned to you if this is possible? Yes No 53. Do you have any dietary requirements? Yes No (If yes) Specify Vegetarian Vegan Diabetic Gluten free Halal Dairy free Other Other dietary requirements: 54. Do you have any specific food dislikes? For allergies or intolerances, refer to question 46 Yes No (If yes) Specify SECTION C: IN PREPARATION FOR YOUR PROCEDUREC1. MEDICAL PROCEDURE HISTORY55. Have you previously had any procedure / operations or other hospital admissions?(Required) Yes No If yes, please outline your previous admissions in the table below.ProceduresProcedure or eventYearHospital Add RemoveC2. ANAESTHESIA CONSIDERATIONS56. Have you had an anaesthetic before? Yes No (If yes) Specify General Spinal Epidural Unsure 57. Do you have any dental features? Yes No (If yes) Specify Upper denture Lower denture Crown(s) / cap(s) Partial plate Loose or chipped teeth 58. Do you drink alcohol? Yes No (If yes) How many standard drinks per week? C3. PERSONAL ITEMSDo you use any of those personal items?59. Mobility aids, such as a walking stick or cane:(Required) Yes No (If yes) Specify 60. Glasses or contact lenses:(Required) Yes No (If yes) Specify 61. Hearing aids: Yes No (If yes) Specify 62. Earrings or other piercing jewellery: Yes No (If yes) Specify C4. BLOOD CLOT AND INFECTION CONSIDERATIONS63. Have you completed the pre-admission risk assessment in the 'Blood Clots and You' brochure? Yes No 64. Have you recently been on a long distance flight? Yes No 65. In the past 3 days, have you had, or been in contact with anyone who has had, vomiting or diarrhea? Yes No 66. In the past 7 days, have you experienced flu-like symptoms, or been in contact with anyone diagnosed with influenza?(Required) Yes No 67. In the past 4 weeks, have you had a head cold, throat or chest infection, or bronchitis?(Required) Yes No 68 a. In the past 12 months, have you travelled overseas? If yes, please specify when and where?(Required) Yes No If yes, please specify when and where below.specify 68 b. n the past 12 months have you been a patient or employee in a hospital or rest home in New Zealand or overseas? If yes, please specify the Hospital, ward number and when?(Required) Yes No If yes, please specify when and where below.specify 69. Do you have any boils, cuts, sores, scratches or other skin or urine infections?(Required) Yes No (If yes) Specify C5. OTHER CONCERNSIn the days leading up to your scheduled surgery you will speak to one of our Pre-Admit Registered Nurses about the information you have provided in these forms. On the day of your admission, you will see your surgeon, anaesthetist, a nurse and admin staff prior to your scheduled surgery/procedure. They will be able to assist you with any of the information you have provided in this form as well as discuss any anxieties, concerns, or questions you may have. SECTION D: YOUR CURRENT MEDICINESFor your safety, it is extremely important that your doctors and nurses know precisely which medicines you are currently using. Important instructions. List below all medicines you currently use, and bring them with you to the hospital in their original containers If you have a medication card or printout from your GP or pharmacist, please bring it with you to the hospital, as well as completing the list below D1. YOUR CURRENT MEDICINESPlease list all of medicines you currently use.ccName of medicineStrengthHow much you use and when Add Remove(E.g. Paracetamol, 500mg, 2 capsules every 6 hours) {all_fields} Δ
