Craig Coghlan
Dr Lisa Kenway
Liz Vallins
Margot Heaney
Mick Reid
Multi-source Feedback (Anaesthesia Practice)
Smile on questionnaire – TEST VERSION
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Smile on questionnaire – TEST VERSION

SMILE ON ANAESTHETISTS

WE can lay it all out how we want!

Please experiment- a lot of the questions use smart logic, so follow up only appears if you answer yes.

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– Step 1 of 9

Pre-Operative questionnaire

Name *

First

Last

Are you the patient?

Gender *

Male
Female
Other

Phone

Please provide an email as medication instructions will be sent to this email address

Date of Birth

Age *

OPERATION DETAILS

Surgeon *

Hospital *

Operation *

Procedure being performed – in your own words

Date of operation – if known.

Write unknown if no date yet

Why are you having this operation?

In your own words

PATIENT DETAILS

Height (cm)

Weight (kg)

Are you well at present? *

Yes – I am currently well
No – I have been ill

e.g – a recent fever, cough, cold, flu, sore throat, respiratory symptoms, shortness of breath, runny nose, blocked nose, headache, body aches, muscle or joint pains, nausea, diarrhoea, vomiting, loss of smell/taste, loss of appetite, fatigue or any other illness recently.

If you have been UNWELL, please provide further details.

Have you had Covid-19? *

What was the date or your positive test

Are you vaccinated?

What symptoms did you have with covid?

Asymptomatic
Mild – Cough, cold, sore throat etc – But felt well otherwise
Moderate – Symptoms as above – But felt unwell
Severe – Hospitalised due to covid

ANAESTHETIC HISTORY

Have you ever had an anaesthetic? *

Yes
No – I have never had a previous anaesthetic

Have you ever had any anaesthetic complications or problems?

Yes
No
Unsure

Please detail YOUR previous anaesthetic problems – e.g. severe nausea/vomiting, perioperative cardiac events etc.

Please include the name of the hospital(s) these occurred at.

Have any of your BLOOD RELATIVES had a problem with anaesthetics?

Yes
No – Not that I’m aware of

Please provide details of your BLOOD RELATIVES problems with anaesthetics.

MEDICAL CONDITIONS

Heart and Cardiovascular

Have you had any trouble with your HEART or CARDIOVASCULAR system? (this could include Chest pains, Angina, Heart attacks, coronary artery stents, coronary artery bypass surgery, heart rhythm problems, having a pacemaker, defibrillator, strokes or mini-strokes) *

Please provide details of any HEART or CARDIOVASCULAR problems. (Please include your Cardiologist’s name and contact details if applicable.)

Have you been diagnosed with HIGH BLOOD PRESSURE *

Please answer yes if you are on a blood pressure medication, even if your blood pressure is currently normal

Respiratory (lungs)

Have you had any trouble with your RESPIRATORY system (LUNGS)? (this could include asthma, obstructive sleep apneoa, cycstic fibrosis etc) *

Please provide details of any RESPIRATORY (LUNG) problems. (Please include your Respiratory (lung) physician’s name and contact details if applicable)

Do you take any inhalers?

Please take your normal inhalers on the morning of surgery and bring them with you.

Have you been diagnosed with Obstructive Sleep Apnoea? (OSA)

Do you have a CPAP machine?

Please select which best describe your exercise tolerance (You can select more than one) *

I can walk up two flights of stairs (26-30 steps)
I can walk up one flight of stairs (13-15 steps)
I can walk more than 1km on the flat
I can walk 500m on the flat
I can walk 300m on the flat
I can walk 100m on the flat
I can walk 50m on the flat
I can walk around my house

Do you smoke?

Yes – I am a current smoker
No – I am an ex-smoker
No – I have never smoked

How many cigarettes do you smoke on an average day?

How long ago did you quit smoking?

When you did smoke, how many a day (on average) would you smoke?

Diabetes

Are you a DIABETIC? *

How is your diabetes treated? – Please select all that apply to you.

Insulin – I inject myself
Insulin pump – I wear a pump
Tablet
Diet
Non-insulin injectable agents – Ozempic, Wegovy, Rybelsus

Thyroid disease

Have you ever been diagnosed with THYROID disease? *

Yes
No
Unsure

Please select any that apply to your THYROID. (multiple options can be selected).

Underactive thyroid (Hypothyroid)
Overactive thyroid (Hyperthyroid)
Previous thyroid surgery
Goitre (Have you been diagnosed with one)
Your last blood tests were within 12 months
Your last blood tests were normal

Neurological (Brain)

Have you ever been diagnosed with a NEUROLOGICAL (BRAIN) condition? (eg. stroke, TIA, Multiple sclerosis, brain aneurysm, Parkinson’s disease, Epilepsy, Alzheimer’s disease, dementia, etc.) *

Please provide details of any NEUROLOGICAL problems. (Please include your NEUROLOGIST/NEURO-SURGEON’S name and contact details if applicable)

Renal (Kidney)

Have you ever been diagnosed with a RENAL (KIDNEY) condition? (eg. poor kidney function, kidney failure etc.) *

Please provide details of any RENAL (KIDNEY) problems. (Please include your NEPHROLOGIST (KIDNEY SPECIALIST’S) name and contact details if applicable)

Haematological (blood)

Have you ever had a blood clot, bleeding disorder or excessive bleeding? (e.g. deep vein thrombosis (DVT), pulmonary embolism (PE), leukaemia, haemophilia or any other BLOOD condition). *

Please provide details of any HAEMATOLOGICAL (BLOOD) problems. (Please include your /HAEMATOLOGIST (BLOOD SPECIALIST’S) name and contact details if applicable).

Gastrointestinal

Do you have gastro-oesophageal reflux disease (GORD), gastritis, oesophagitis, stomach or duodenal ulcers, hiatus hernia? *

Please select any which apply to you (multiple options can be selected)

You suffer from acid indigestion or reflux
You previously suffered from acid indigestion or reflux but currently do not due to medication.
I’ve had a gastric band or gastric sleeve surgery.

Medications

Do you have any allergies? (e.g. medications, antibiotics, latex, iodine, food). *

ALLERGIES – Please list all your allergies.

Do you take any regular MEDICATIONS? *

This includes all syrups, tablets, puffers, patches, sprays, injections, eye drops, vitamins and herbal remedies etc.

MEDICATION LIST (If you have a PDF/ JPG copy you can upload this instead)

MEDICATION LIST

Drag & Drop Files, Choose Files to Upload

Please upload a PDF or JPEG copy of your medication list

Medication instructions

Below are some more detailed questions about your regular medications – please read them carefully and ensure you have your medications with you, so you can compare the generic name (mutliple medications have many brand names).

Do you take WEGOVY, OZEMPIC, RYBELSUS? *

These are prescribed either for diabetes or weight control.

What insulin do you take?

Basal insulin – Glargine (Optisulin™, Toujeo™, Semglee™), Detemir (Levemir™), isophane insulin (Protaphane™, Humulin NPH™), Degludec (tresiba)
Pre-mixed insulin – Novomix™ 30, Mixtard™ 30/70, Humalog Mix™ 25, Humulin 70/30, Novolin 70/30, Novolog 70/30, Humulin 50/50, Humalog mix 75/25
Co-formulated insulin – Ryzodeg 70/30
Bolus insulin – aspart-FiAsp™,insulin lispro – Humalog™, insulin aspart – Novorapid™, insulin glulisine – Apidra™, Actrapid™, Humulin R™).

Insulin instructions for your procedure (Basal insulin)-

(this will be emailed to the email address you provided when you press submit)

Please read carefully:

Basal insulin – Glargine (Optisulin™, Toujeo™, Semglee™), Detemir (Levemir™), isophane insulin (Protaphane™, Humulin NPH™), Degludec (tresiba)

The day before surgery:
- am dose – 100% of usual dose
- pm dose – 100% of usual dose
The day of surgery:
- am dose – 80% of usual dose

If you have provided an email address, these instructions will automatically be emailed to you (they are within the body of the email with your answers to this questionnaire). If you have not provided an email, please note these down before moving to the next screen.

Insulin instructions for your procedure (Pre-mix insulin)-

Please read carefully:

Pre-mixed insulin – Novomix™ 30, Mixtard™ 30/70, Humalog Mix™ 25, Humulin 70/30, Novolin 70/30, Novolog 70/30, Humulin 50/50, Humalog mix 75/25

Type 1 diabetic (usually diagnosed early in life and immediately put onto insulin)
- The day before surgery:
  - 100% of usual dose
- The day of surgery:
  - am dose = 50% of usual dose

Insulin instructions for your procedure (Co-formulated insulin)-

Please read carefully:

Co-formulated insulin – Ryzodeg 70/30

Type 1 diabetic (usually diagnosed early in life and immediately put onto insulin)
- The day before surgery:
  - 100% of usual dose
- The day of surgery:
  - If fasting – omit
  - If allowed a light breakfast – take 50% of usual dose

Insulin instructions for your procedure (bolus insulin)-

(this will be emailed to the email address you provided when you press submit)

Please read carefully:

Bolus insulin – aspart-FiAsp™,insulin lispro – Humalog™, insulin aspart – Novorapid™, insulin glulisine – Apidra™, Actrapid™, Humulin R™).

The day before surgery:
- 100% of usual dose
The day of surgery
- Do NOT take

Insulin pump

Please ensure your insertion site for your line is NOT close to your surgical site.
If you are staying in hospital for more than one night – please ensure you change your line and set the day prior to admission.
If the your glycaemic control is tight, eg you get frequent hypoglycaemic episodes, your HbA1c is less than 48 mmol/mol (6.5%) or a fasting BGL of <5 mmol/L in recent weeks. Reduce your baseline rate of insulin to 80% of your normal dose when you commence fasting (ie if you are fasting from midnight, reduce the insulin dose before you go to bed).
If you have normal glycaemic control/ or are unsure if the above applies to you – leave your baseline rate of insulin at its normal rate.

What diabetic tablets do you take?

SGLT2 agents – dapagliflozin, empagliflozin, ertugliflozin, Forxiga, Glyxambi, Jardiance, Jardiamet, Qtern, Segluromet, Steglatro, Steglujan, Xigduo.
All other diabetic tablets

Please check the name on the box as they sometimes have several different trade names

Instructions SGLT2 agents – dapagliflozin, empagliflozin, ertugliflozin, Forxiga, Glyxambi, Jardiance, Jardiamet, Qtern, Segluromet, Steglatro, Steglujan, Xigduo.

For day-stay procedures- you are going home the same day as your operation – SGLT2 can be stopped just for the day of procedure.

For all other diabetic tablets

(these instructions are NOT for the tablets classed as SGLT2 agents)

On the day before your procedure – take your tablets as you normally would.

On the day of the procedure – DO NOT take your diabetic tablets

Do you take any Non-insulin injectable agents – Ozempic, Wegovy, Rybelsus

Non-insulin injectable agents – Ozempic, Wegovy, Rybelsus

These can increase the time it takes for food to pass out of your stomach.

Our usual fasting guidelines should be increased – so please do NOT have any food for at least 12 hours prior to your admission time (this may be longer than you are told over the phone, but please stick to the longer time).

Do you take any of the listed blood pressure medications? ACEi – Ramipril (Prilace, Tritace, Tryzan, Triasyn), Perindopril (Idaprex, Indosyl Mono, PERISYL, Perindo, Prexium, Coversyl, Reaptan, Coveram, ), Captopril (Capoten), Enalapril (Acetec, Malean, Renitec), Trandolapril (Dolapril, Tranalpha, Gopten, Tarka). ARB – Irbesartan (AVSARTAN, Abisart, Avapro, Karvea, Karvezide), Valsartan (Dilart, Diovan, Co-Diovan), Olmesartan (OLMERTAN, Olsetan, Olmetec, OLMEKAR, Sevikar, Olamlo, Olmekar, ), Candesartan (Adesan, CANDESAN, Atacand)

Instructions for:

ACEi – Ramipril (Prilace, Tritace, Tryzan, Triasyn), Perindopril (Idaprex, Indosyl Mono, PERISYL, Perindo, Prexium, Coversyl, Reaptan, Coveram, ), Captopril (Capoten), Enalapril (Acetec, Malean, Renitec), Trandolapril (Dolapril, Tranalpha, Gopten, Tarka).

ARB – Irbesartan (AVSARTAN, Abisart, Avapro, Karvea, Karvezide), Valsartan (Dilart, Diovan, Co-Diovan), Olmesartan (OLMERTAN, Olsetan, Olmetec, OLMEKAR, Sevikar, Olamlo, Olmekar, ), Candesartan (Adesan, CANDESAN, Atacand)

Please do NOT take on the day of surgery – but ensure you bring them with you to the hospital.

Have you taken a course of steroids within the last 3 months that is NOT mentioned in your medication list? (e.g. prednisone, prednisolone, hydrocortisone, etc.)

Please specify the name, duration and dose of the steroids you have taken within the last 3 months.

Teeth/ Dentition

Please select all that apply to you with regards to your teeth/ dentition *

Your own teeth (with or without fillings)
Loose tooth/ teeth
Chipped tooth/ teeth
Caps, crowns, veneers
Upper denture – FULL
Upper denture – PARTIAL
Lower denture – FULL
Lower denture – PARTIAL
Braces/ wires
Implant(s)
Bridge(s)
NO teeth

Please provide any further details of your dentition.

Neck

Do you have any limitations in the movement of your neck or problems with your neck? *

Please provide details of any neck issues you have.

Airway

Have you ever been told you have a difficult airway during a previous anaesthetic? *

Please provide information on any airway issues you have been informed about.

Please upload any documentation you have about your difficult airway

Drag & Drop Files, Choose Files to Upload

Any other comment?

If you have any other information you would like to tell Dr Vallins prior to your surgery, please write below

Smile on questionnaire – TEST VERSION

SMILE ON ANAESTHETISTS

Pre-Operative questionnaire

OPERATION DETAILS

PATIENT DETAILS

ANAESTHETIC HISTORY

MEDICAL CONDITIONS

Heart and Cardiovascular

Respiratory (lungs)

Please take your normal inhalers on the morning of surgery and bring them with you.

Diabetes

Thyroid disease

Neurological (Brain)

Renal (Kidney)

Haematological (blood)

Gastrointestinal

Medications

Medication instructions

Insulin instructions for your procedure (Basal insulin)-

Insulin instructions for your procedure (Pre-mix insulin)-

Insulin instructions for your procedure (Co-formulated insulin)-

Insulin instructions for your procedure (bolus insulin)-

Insulin pump

Instructions SGLT2 agents – dapagliflozin, empagliflozin, ertugliflozin, Forxiga, Glyxambi, Jardiance, Jardiamet, Qtern, Segluromet, Steglatro, Steglujan, Xigduo.

For all other diabetic tablets

Non-insulin injectable agents – Ozempic, Wegovy, Rybelsus

Instructions for:

Teeth/ Dentition

Neck

Airway

Other documentation

Any other comment?