Pre-Admission Screening

01 Patient Details

Full Name *

Date of Birth *

H&C Number

Address *

Mobile Number *

02 Procedure Details

Procedure Type *

Procedure Date *

Consultant

03 Next of Kin & Collection

Next of kin must be present if patient is unable to consent.

Next of Kin

Name

Contact Number

Responsible Adult for Collection

Name

Contact Number

04 Allergies & Sensitivities

Include any drugs, latex, elastoplast/tapes/dressings, foods, solutions, creams, etc.
If you have an EpiPen, please bring it with you to your appointment.

Do you have any known allergies or sensitivities?

Yes No

Please list all allergies and sensitivities

05 Health Questions

Any diarrhoea or vomiting in the past 2–3 weeks?

Yes No

Any flu or cold symptoms in the last 2–3 weeks?

Yes No

Ever had a hospital acquired infection (e.g. MRSA, C. difficile)?

Yes No

Ever had any blood borne infections (e.g. Hepatitis A or HIV)?

Yes No

Are you a smoker?

Yes No

How many per day?

Do you require an interpreter?

Yes No

Language required

Any visual or hearing impairment?

Yes No

Please provide details

06 Medical History

Please answer Yes or No for each condition and include any important details below.

Cardiac problems

Yes No

Pacemaker

Yes No

DVT / PE

Yes No

Asthma

Yes No

Diabetes

Yes No

Epilepsy

Yes No

High / Low blood pressure

Yes No

Stomach ulcers

Yes No

Pregnancy

Yes No N/A

Date of Last Period (if applicable)

Any previous surgery and/or complications?

Additional medical history notes

07 Medications

Please list all medications, creams, patches, etc. Include all blood thinners, steroids, herbal remedies, etc.

Current Medications

08 Completing on Behalf of Patient

Are you completing this form on behalf of the patient?

No — I am the patient Yes — completing on behalf of patient

Does the patient reside in nursing / residential accommodation?

Yes No

Is transport booked by the home?

Yes No N/A

Is the patient mobile? (can transfer onto couch without hoist)

Yes No

Who will accompany the patient to and from the appointment?

09 Declaration

I confirm that the information provided is accurate to the best of my knowledge.

Signature *

Sign here with your finger or mouse

Date

Thank you