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Pre-Assessment Form

1 Step 1
Your Details
Genderpick one
*Please note your weight shall be checked again at your pre-operative assessment appointment 14 days prior to surgery. If your weight has increased significantly since you were last seen this may have an impact on your surgery cost, if BMI has exceeded our limit of 30 this will result in a postponement of surgery.*
Your Surgery
Additional Information
Do you have an special dietary requirementspick one
Bloods to be arranged by (FBC U&E)pick one
MRSA screening to be arranged by (nose/throat/groin)pick one
Known allergiespick one
Do you havepick one
Will you have someone to take you home after your procedurepick one
DAY CASE PATIENTS - should stay no more than 1hour drive from the hospital on the first night post operatively.
Please provide their details
At home
Will you have someone at home to look after you for 24 hours
Will you have access to a telephone
Do you have name and contact number for next of kin
Please provide their details
Do you give consent to the clinic nurse contacting you following discharge
Covid-19
Have you tested positive for Covid-19
Have you been vaccinated for Covid-19?
Vaccination should not be 1 week prior to any surgery or for a period of 2 weeks post surgery (GA/Sedation) & 1 week (local anaesthetic)
Menstrual cycle
Are you takingpick one
Medical history
Have you ever had any of the following
Have you ever had any of the following
Have you ever had any of the following
Have you ever had any of the following
Have you ever been referred to
Have you ever had any of the following
Do you smoke
Smoking must be stopped at least 6 weeks prior to surgery
Do you drink alcohol
Do you use recreational drugs
Recreational drugs must be stopped at least 6 weeks prior to surgery
Do you have any of the following
Are you taking
Patients must refrain from Aspirin 1 week before and after surgery. Refrain from Ibuprofen/Neurofen 48 hours before surgery.
Are you having a plastic or cosmetic procedurepick one
Hospital Anxiety and Depression Scale (HADS)- Part 1 Anxiety. Tick the box beside the reply that is closest to how you have been feeling int he past week. Don't take too long over your replies: your immediate is best.
I feel tense or wound uppick one
I get a sort of frightened feeling as if something awful is about to happenpick one
Worrying thoughts go through my mindpick one
I can sit at ease and feel relaxedpick one
I get a sort of frightened feeling like butterflies in the stomachpick one
I feel restless as I have to be on the movepick one
I get sudden feelings of panicpick one
Hospital Anxiety and Depression Scale (HADS)- Part 2 Depression. Tick the box beside the reply that is closest to how you have been feeling int he past week. Don't take too long over your replies: your immediate is best.
I still enjoy the things I used to enjoypick one
I can laugh and see the funny side of thingspick one
I feel cheerfulpick one
I feel as if I am slowed downpick one
I have lost interest in my appearancepick one
I look forward with enjoyment to thingspick one
I can enjoy a good book, or radio, or TV programmepick one
Body Image
Are you very concerned about the appearance of some part(s) of your body that you consider particularly unattractivepick one
Is your main concern with how you look that you aren't thin enough or that you might become too fatpick one
Has your defect(s) often caused you a lot of distress, torment or emotional painpick one
Has your defect(s) often significantly interfered with your social lifepick one
Has your defect(s) often significantly interfered with your school work, your job or your ability to functionpick one
Are there things you avoid because of your defect(s)pick one
Have the lives or normal routines of your family or friends been affected by your defect(s)pick one
Pre & Post Information Checklist
I have been informed and understand due to my medical history and or the nature of my operation, it is necessary for me to have pre-operative test(s)/investigation(s) performed. I am aware of the significance of results outside of 'normal range'. Declaration I confirm that the above information about my health history is true and complete and accept responsibility for any repercussions that may occur if I omit or manipulate any facts.
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