Please NOTE:

Free text fields in the form have character limits and so if the colour changes to light red it means the limit is exceeded, and you should use the backspace key to reduce the text, until the background is white.
Any field marked * is a mandatory field and the form will not submit until all these fields are filled.
This form will be sent to: Hamilton hospital Tick here to send a copy to your email address, as provided in the form.

Patient Admission Form

Next of kin/contact person

Name:

Relationship to patient:

Address:

Telephone: (Home)

(Business)

(Mobile)

Agreement

I agree to settle my Hospital account in full at the time of my discharge when personally paying my account or where I do not have “prior approval” from my insurer. I understand I am responsible for any outstanding balance if my procedure is not fully covered by insurance, ACC or other contract.

I give permission for Southern Cross Healthcare to obtain any information relating to the approval/claim for this admission from the relevant funder/s, and I authorise that person or organisation to disclose such information to Southern Cross Healthcare. I accept that, in the event my Hospital account is not met, Southern Cross Healthcare reserves the right to add all costs of collection to this account.

I give permission to Southern Cross Healthcare or any health professional (such as my medical specialist) involved in my care in relation to this admission to Hospital, to access health information about me that is relevant to my treatment (including pre-admission and after discharge), which may be held by Southern Cross Healthcare, other health professionals or other health organisations. I understand that other clinical team members such as student nurses and qualified medical trainees may have supervised involvement with my care and that I have the right to decline their presence or contribution to my care delivery.

I understand the admitting Surgeon, Anaesthetist and other Doctors or health professionals using Southern Cross Healthcare facilities are independent and not employees of Southern Cross Healthcare, with respect to both my treatment, care and account payment. I accept that this agreement is covered by New Zealand law. The details above have been completed by:

*Name:

*Date:

Signature: (To be signed at the hospital upon admission)

If not the patient, state relationship to patient:

Patient Health Questionnaire

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

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 relating to the patient’s health.

PLEASE NOTE: To support your ongoing care, your discharge information will be sent to your nominated GP.
Please tick here if you do NOT want this.

Section A: Your General Health

A1	Medical procedure health alerts
Do any of the following apply to you?
Q	Yes	No
1			Difficulty climbing more than a flight of stairs	What restricts this activity?
2			Motion sickness	mild moderate severe
3			Jaw problems (difficulty opening mouth)	Specify:
4			Problems with a previous anaesthetic	Specify:
5			Family history of problems with an anaesthetic	Specify:
6			Pacemaker or heart valve replacement	Specify:
7			Joint implants	Specify:
8			Other implant or prostheses and metalware	Specify:
9			Substance use or dependency	Specify:
10			Former smoker	When did you quit?
11			Currently on smoking cessation treatment	Specify:
12			Current smoker	How many per day?
13			Vaping	How many times per day?
14			Pregnant or possibly pregnant	Approximate due date:
15			Breastfeeding
16			MedicAlert bracelet or necklace wearer	Specify:

Your medical conditions

Do you currently have, or have you previously had, any of the following conditions?
If you answer YES to any of the following questions (17-46), please use the box beneath Question 46 to provide information, including the question number.

Yes

Breathing conditions: asthma wheeziness shortness of breath bronchitis croup emphysema COPD

Sleeping conditions: sleeplessness severe snoring obstructive sleep apnoea CPAP used

Heart conditions: palpitations irregular heart beat heart murmur angina heart attack chest pain congestive heart failure rheumatic fever

Stroke or Transient Ischaemic Attack (TIA)

High blood pressure or blood pressure controlled with medication

Blood clots: deep vein thrombosis (DVT) pulmonary embolus (PE)

Family history of blood clots

Blood or bleeding conditions: anaemic bruising

Family history of blood or bleeding conditions

Stomach and digestive conditions: indigestion heartburn acid reflux hiatus hernia peptic ulcer

Bowel conditions: irritable bowel syndrome constipation bowel disease

Liver disease: jaundice hepatitis

Kidney conditions

Diabetes: type 1 type 2 requiring insulin requiring tablets diet controlled

Thyroid conditions

Parkinson's disease

Epilepsy, seizures, blackouts or fainting

Migraines or severe headaches

Alzheimers or dementia

Mental function conditions: head injury concussion confusion or disorientation

Mental health conditions

Emotional conditions: anxiety phobia post traumatic stress disorder (PTSD)

Arthritis: osteoarthritis rheumatoid other

Neck or back conditions

Gum or dental health conditions

Tuberculosis (TB)

HIV or AIDS

Infection or treatment for resistant organisms: MRSA ESBL VRE OTHER

Cancer
- If Yes, please specify and provide details of any recent treatment in the Comments box below

Other condition(s) not listed above
- If Yes, please specify in the Comments box below

Re question	Your comment
21. GP says my blood pressure is slightly high, but I am not taking any medicine. ----Example----

Section B: In preparation for your hospital admission

Your allergies, sensitivities, or intolerances

Yes

Are you allergic to latex?

Do you have any other allergies, sensitivities or intolerances?
- If Yes, please specify and describe the reaction using the box below. NOTE: If you need more room to provide details, use the text box at the foot of Section D of this form, including the question number with your notes.

	Item	Reaction
Skin-related
Medicine-related
Food-related
Other

B2	Your needs and preferences
Please 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.*
Q	Yes	No		If yes
49			Do you have a disability?	Specify:
50			Do you have difficulty understanding English?	Your preferred language:
51			Do you have any religious or spiritual needs you would like us to know about?	Specify:
52			Do you have any cultural or family needs you would like us to know about?	Specify:
53			Do you have any other special needs you would like us to know about?	Specify:
54			If your procedure requires the removal of body parts, would you like them returned to you if this is possible?
55			Do you have any dietary requirements? vegetarian vegan diabetic gluten free halal dairy free bottle fed breast fed other
56			Do you have any specific food dislikes? For allergies or intolerances, refer to question 48	Specify:

Section C: In Preparation For Your Procedure

Medical procedure history

Height

Weight

Yes

Have you previously had any procedures / operations or other hospital admissions?
- if Yes, please outline your previous admissions in the table below.

Procedure or event	Year	Hospital

C2.	Anaesthesia considerations
Q	Yes	No
58			Have you had an anaesthetic before? general spinal epidural unsure
59			Do you have any of these dental features? upper denture lower denture crown(s) / cap(s) partial plate loose or chipped teeth
60			Do you drink alcohol? How much?

C3.	Personal items
Do you use any of these personal items?
Q	Yes	No
61			Mobility aids such as a walking stick or cane?
62			Glasses or contact lenses
63			Hearing aids
-If Yes* above, use this space to provide details, if needed, using the question number(s) for reference.*

C4.	Blood clot and infection considerations
Q	Yes	No
64			Have you completed the pre-admission risk assessment in the "Blood Clots and YOU" brochure?
65			Have you recently been on a long distance flight? -If Yes, when?
66			If your operation is within the next 3 days: Have you had, or been in contact with anyone who has had vomiting or diarrhoea?
67			If your operation is within the next 7 days: Have you experienced flu-like symptoms, or been in contact with anyone diagnosed with influenza?
68			If your operation is within the next 4 weeks: Have you had a head cold, throat or chest infection, or bronchitis?
69			In the past 12 months, have you travelled overseas? -If Yes, please specify the country:
70			In 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 country:
71			Do you have any boils, cuts, sores, scratches or other skin infections? -If Yes, please specify:
72			Do you have (or have you recently had) a urine infection? -If Yes, please specify:

C5.	Other concerns
Q	Yes	No
73			Is there anything we need to know that you prefer not to write on this questionnaire? -If Yes, please discuss with your nurse or medical specialist when you arrive at the hospital
74			Do you have anxieties, concerns, or questions you wish to discuss before your procedure? - if Yes, who would you like to speak with? your surgeon your anaesthetist a nurse one of our admin. staff

Section D: Your Current Medicines

For your safety, it is extremely important that your doctor 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 are taking any blood thinning medication or supplements, check with your surgeon if these need to be stopped prior to your admission.
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.

MEDICINE REMINDERS Which of the examples below apply to you?
There are many types of medicine	Medicines come in many forms	Medicines are taken for many common conditions
prescription medicines herbal medicines natural medicines homeopathic medicines over-the-counter-medicines vitamins supplements contraceptives steroids	tablets capsules inhalers drops syrups patches suppositories creams injections other liquids	heart disease high blood pressure blood thinning dietary deficiencies emotional conditions infections diabetes sleeplessness epilepsy

D1. Your current medicines			Hospital use only
Patient to complete - list all medicines you currently use.			Reconciled: Yes () \| No (x) \| Not available (NA)
Name of medicine	Strength	How much you use, and when	Medicine container	Medication card	Patient or whanau/family	Other(state) eg, 'phoned GP'	ON ADMISSION: Date/time last taken
sp. Paracetamol --example--	500mg	2 capsules every 6 hours	-	-	-	-	-
sp. Paracetamol --example--	500mg	2 capsules every 6 hours	Comment if No:				-

			Comment if No:

			Comment if No:

			Comment if No:

			Comment if No:

Name of medicine	Strength	How much you use, and when	Medicine container	Medication card	Patient or whanau/family	Other(state) eg, 'phoned GP'	ON ADMISSION: Date/time last taken

			Comment if No:

			Comment if No:

			Comment if No:

			Comment if No:

			Comment if No:

			Comment if No:

			Comment if No:

			Comment if No:

			Comment if No:

			Comment if No:

			Comment if No:

Please provide any additional comments in the space below with the question number for reference if appropriate (for example, using this space for any details relating to allergies, sensitivities, intolerances or medication information):

NOTE: If a requested form does not reach you soon after submission, we suggest checking any Junk mail folders before contacting us. Thank you.

This form will be sent to: Hamilton hospital Tick here to send a copy to your email address, as provided in the form.

Please NOTE:

Free text fields in the form have character limits and if the colour changes to light red it means the limit is exceeded and should be reduced, until it is white.
Any field marked * is a mandatory field and the form will not submit until all these fields are filled.