Peri-Operative Care Plans

Pre-Operative Care Plan Template


Key Objectives

Provide patients with a digital care plan providing them with pre-operative information and their assessment for day surgery.


Outcome measures

Equip patients with the information and assessment that's completed before day surgery admissions for surgery.


Current Baselines

Patients don't currently have access to the pre-operative assessment completed by the team.

Example HTML code for Pre op care plan template

<div class="form-inline">

<style media="screen">

a {word-wrap: break-word;}

.form-group {width: 100%; !important}

.cp_whiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; border-radius: 10px; border: 3px solid #014151;}

.cp_separator {height: 3px; background-color: #898989; margin-top: 5px; margin-bottom: 5px;}

</style>

<div class="cp_whiteBox">

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_preferName">Preferred Name:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_preferName" id="cp_preferName" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_escortName">Named Escort:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_escortName" id="cp_escortName" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_escortNameTel">Telephone No:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_escortNameTel" id="cp_escortNameTel" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_escortNameNOK">Next of Kin:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_escortNameNOK" id="cp_escortNameNOK" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_escortNameNOKtel">Telephone No:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_escortNameNOKtel" id="cp_escortNameNOKtel" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_dataSharePerson">Name of person patient agrees information can be shared with:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_dataSharePerson" id="cp_dataSharePerson" class="form-control" style="width: 100%;"/>

</div>

</div>

<hr class="cp_separator"/>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_GPname">GP Name:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_GPname" id="cp_GPname" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_GPaddress">Address:</label>

<textarea class="form-control" name="cp_GPaddress" id="cp_GPaddress" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_GPtel">Telephone No:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_GPtel" id="cp_GPtel" class="form-control" style="width: 100%;"/>

</div>

</div>

<hr class="cp_separator"/>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_consultant">Consultant:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_consultant" id="cp_consultant" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_consultantDept">Department:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_consultantDept" id="cp_consultantDept" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_proposedProcedure">Proposed Procedure: </label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_proposedProcedure" id="cp_proposedProcedure" class="form-control" style="width: 100%;"/>

</div>

</div>

<hr class="cp_separator"/>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_surgeryDate">Date to attend Day Surgery Unit:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_surgeryDate" id="cp_surgeryDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_preadmissionDate">Pre-admission contact date: </label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_preadmissionDate" id="cp_preadmissionDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<hr class="cp_separator"/>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_namedNurse">Named Nurse:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_namedNurse" id="cp_namedNurse" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_primaryNurse">Primary Nurse:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_primaryNurse" id="cp_primaryNurse" class="form-control" style="width: 100%;"/>

</div>

</div>

</div>

<div class="cp_whiteBox">

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_preassessmentDate">Date of Pre-assessment:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_preassessmentDate" id="cp_preassessmentDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_preassessmentTime">Time of Pre-assessment:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_preassessmentTime" id="cp_preassessmentTime" class="form-control" style="width: 100%;" placeholder="HH:MM" maxlength="5"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_nurseComments">Pre-assessment nurse's comments:</label>

<textarea class="form-control" name="cp_nurseComments" id="cp_nurseComments" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_nurseSignature">Signature:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_nurseSignature" id="cp_nurseSignature" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_nurseGrade">Grade:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_nurseGrade" id="cp_nurseGrade" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_nurseDate">Date:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_nurseDate" id="cp_nurseDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

</div>

<div class="cp_whiteBox">

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Special needs discussed at Pre-assessment:</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_specialNeedsDiscussed1" id="cp_specialNeedsDiscussed1" value="Large Print"/>

<label class="cp_label" for="cp_specialNeedsDiscussed1">Large Print</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_specialNeedsDiscussed2" id="cp_specialNeedsDiscussed2" value="Audio Tape"/>

<label class="cp_label" for="cp_specialNeedsDiscussed2">Audio Tape</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_specialNeedsDiscussed3" id="cp_specialNeedsDiscussed3" value="Other Language"/>

<label class="cp_label" for="cp_specialNeedsDiscussed3">Other Language</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_specialNeedsDiscussed4" id="cp_specialNeedsDiscussed4" value="Special Diet"/>

<label class="cp_label" for="cp_specialNeedsDiscussed4">Special Diet</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_specialNeedsDiscussed5" id="cp_specialNeedsDiscussed5" value="Spiritual Needs"/>

<label class="cp_label" for="cp_specialNeedsDiscussed5">Spiritual Needs</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_specialNeedsDiscussed6" id="cp_specialNeedsDiscussed6" value="Mixed Sex Environment"/>

<label class="cp_label" for="cp_specialNeedsDiscussed6">Mixed Sex Environment</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_specialNeedsDiscussed7" id="cp_specialNeedsDiscussed7" value="Complaints Procedure"/>

<label class="cp_label" for="cp_specialNeedsDiscussed7">Complaints Procedure</label>

</div>

</div>

</div>

</div>

<div class="cp_whiteBox">

<h2>PATIENT TO COMPLETE:</h2>

<h2>ASSESSMENT FOR ADULT CARE IN THE DAY SURGERY UNIT</h2>

<h3>Will You:-</h3>

<div class="row">

<div class="col-sm-4">

<p>1. have someone to take you home?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_1" id="cp_haveYouYes_1" value="Yes">

<label class="form-check-label" for="cp_haveYou_1"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_1" id="cp_haveYouNo_1" value="No">

<label class="form-check-label" for="cp_haveYou_1"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_1" id="cp_haveYouComments_1" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>2. provide your own transport?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_2" id="cp_haveYouYes_2" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_2"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_2" id="cp_haveYouNo_2" value="No">

<label class="form-check-label" for="cp_haveYouNo_2"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_2" id="cp_haveYouComments_2" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>3. have a telephone at home?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_3" id="cp_haveYouYes_3" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_3"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_3" id="cp_haveYouNo_3" value="No">

<label class="form-check-label" for="cp_haveYouNo_3"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_3" id="cp_haveYouComments_3" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>4. have easy access to a lavatory?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_4" id="cp_haveYouYes_4" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_4"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_4" id="cp_haveYouNo_4" value="No">

<label class="form-check-label" for="cp_haveYouNo_4"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_4" id="cp_haveYouComments_4" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>5. have someone to look after you for 24 hours?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_5" id="cp_haveYouYes_5" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_5"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_5" id="cp_haveYouNo_5" value="No">

<label class="form-check-label" for="cp_haveYouNo_5"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_5" id="cp_haveYouComments_5" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<h3>Have you ever suffered from:-</h3>

<div class="row">

<div class="col-sm-4">

<p>6. chest pain?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_6" id="cp_haveYouYes_6" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_6"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_6" id="cp_haveYouNo_6" value="No">

<label class="form-check-label" for="cp_haveYouNo_6"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_6" id="cp_haveYouComments_6" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>7. breathlessness?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_7" id="cp_haveYouYes_7" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_7"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_7" id="cp_haveYouNo_7" value="No">

<label class="form-check-label" for="cp_haveYouNo_7"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_7" id="cp_haveYouComments_7" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>8. chest disease (ie. asthma, bronchitis)?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_8" id="cp_haveYouYes_8" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_8"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_8" id="cp_haveYouNo_8" value="No">

<label class="form-check-label" for="cp_haveYouNo_8"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_8" id="cp_haveYouComments_8" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>9. high blood pressure?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_9" id="cp_haveYouYes_9" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_9"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_9" id="cp_haveYouNo_9" value="No">

<label class="form-check-label" for="cp_haveYouNo_9"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_9" id="cp_haveYouComments_9" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>10. a heart attack or heart murmur?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_10" id="cp_haveYouYes_10" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_10"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_10" id="cp_haveYouNo_10" value="No">

<label class="form-check-label" for="cp_haveYouNo_10"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_10" id="cp_haveYouComments_10" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>11. fainting easily?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_11" id="cp_haveYouYes_11" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_11"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_11" id="cp_haveYouNo_11" value="No">

<label class="form-check-label" for="cp_haveYouNo_11"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_11" id="cp_haveYouComments_11" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>12. fits (epilepsy)?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_12" id="cp_haveYouYes_12" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_12"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_12" id="cp_haveYouNo_12" value="No">

<label class="form-check-label" for="cp_haveYouNo_12"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_12" id="cp_haveYouComments_12" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>13.jaundice (yellowness)?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_13" id="cp_haveYouYes_13" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_13"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_13" id="cp_haveYouNo_13" value="No">

<label class="form-check-label" for="cp_haveYouNo_13"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_13" id="cp_haveYouComments_13" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>14.indigestion or heartburn?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_14" id="cp_haveYouYes_14" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_14"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_14" id="cp_haveYouNo_14" value="No">

<label class="form-check-label" for="cp_haveYouNo_14"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_14" id="cp_haveYouComments_14" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>15.kidney or bladder trouble?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_15" id="cp_haveYouYes_15" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_1"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_15" id="cp_haveYouNo_15" value="No">

<label class="form-check-label" for="cp_haveYouNo_15"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_15" id="cp_haveYouComments_15" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>16. anaemia or other blood problems?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_16" id="cp_haveYouYes_16" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_16"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_16" id="cp_haveYouNo_16" value="No">

<label class="form-check-label" for="cp_haveYouNo_16"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_16" id="cp_haveYouComments_16" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>17. excessive bleeding or bruising?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_17" id="cp_haveYouYes_17" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_17"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_17" id="cp_haveYouNo_17" value="No">

<label class="form-check-label" for="cp_haveYouNo_17"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_17" id="cp_haveYouComments_17" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>18. arthritis?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_18" id="cp_haveYouYes_18" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_18"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_18" id="cp_haveYouNo_18" value="No">

<label class="form-check-label" for="cp_haveYouNo_18"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_18" id="cp_haveYouComments_18" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>19. muscle disease or progressive weakness?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_19" id="cp_haveYouYes_19" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_19"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_19" id="cp_haveYouNo_19" value="No">

<label class="form-check-label" for="cp_haveYouNo_19"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_19" id="cp_haveYouComments_19" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>20. diabetes or pass water very often?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_20" id="cp_haveYouYes_20" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_20"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_20" id="cp_haveYouNo_20" value="No">

<label class="form-check-label" for="cp_haveYouNo_20"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_20" id="cp_haveYouComments_20" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<h3>Have you ever had:-</h3>

<div class="row">

<div class="col-sm-4">

<p>21. an allergy to a general or local anaesthetic?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_21" id="cp_haveYouYes_21" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_21"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_21" id="cp_haveYouNo_21" value="No">

<label class="form-check-label" for="cp_haveYouNo_21"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_21" id="cp_haveYouComments_21" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>22. a serious illness?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_22" id="cp_haveYouYes_22" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_22"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_22" id="cp_haveYouNo_22" value="No">

<label class="form-check-label" for="cp_haveYouNo_22"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_22" id="cp_haveYouComments_22" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>23. an allergy to medicines, Elastoplast etc.?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_23" id="cp_haveYouYes_23" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_23"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_23" id="cp_haveYouNo_23" value="No">

<label class="form-check-label" for="cp_haveYouNo_23"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_23" id="cp_haveYouComments_23" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<h3>Do you:-</h3>

<div class="row">

<div class="col-sm-4">

<p>24. take tablets, medicines, patches etc.? Please specify</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_24" id="cp_haveYouYes_24" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_24"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_24" id="cp_haveYouNo_24" value="No">

<label class="form-check-label" for="cp_haveYouNo_24"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_24" id="cp_haveYouComments_24" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>25. smoke?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_25" id="cp_haveYouYes_25" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_25"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_25" id="cp_haveYouNo_25" value="No">

<label class="form-check-label" for="cp_haveYouNo_25"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_25" id="cp_haveYouComments_25" rows="3" style="width: 100%;" placeholder="Comments(if yes, how much ................)"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>26. drink over 1 1/2 pints of beer or 3 shorts per day?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_26" id="cp_haveYouYes_26" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_26"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_26" id="cp_haveYouNo_26" value="No">

<label class="form-check-label" for="cp_haveYouNo_2"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_26" id="cp_haveYouComments_26" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>27. if a woman, do you take the pill or are you pregnant?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_27" id="cp_haveYouYes_27" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_27"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_27" id="cp_haveYouNo_27" value="No">

<label class="form-check-label" for="cp_haveYouNo_27"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_27" id="cp_haveYouComments_27" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row">

<div class="col-sm-4">

<p>28. need to inform the staff of anything else?</p>

</div>

<div class="col-sm-4">

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_28" id="cp_haveYouYes_28" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_28"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_28" id="cp_haveYouNo_28" value="No">

<label class="form-check-label" for="cp_haveYouNo_28"> No</label>

</input>

</div>

</div>

<div class="col-sm-4">

<textarea class="form-control" name="cp_haveYouComments_28" id="cp_haveYouComments_28" rows="3" style="width: 100%;" placeholder="Comments"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_haveYou_29">29. Please list previous operations:</label>

<textarea class="form-control" name="cp_haveYou_29" id="cp_haveYou_29" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_haveYou_30">30. Please list any complications you have had after surgery or anaesthetics:</label>

<textarea class="form-control" name="cp_haveYou_30" id="cp_haveYou_30" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_haveYou_31">31. When was your last anaesthetic:-</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_haveYou_31" id="cp_haveYou_31" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-4">

<p>32. Has any member of the family had problems with anaesthetics?</p>

</div>

<div class="col-sm-8" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_32" id="cp_haveYouYes_32" value="Yes">

<label class="form-check-label" for="cp_haveYouYes_32"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_haveYou_32" id="cp_haveYouNo_32" value="No">

<label class="form-check-label" for="cp_haveYouNo_32"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>32. Do you have any of the following</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_haveYou_32_1" id="cp_haveYou_32_1" value="dentures"/>

<label class="cp_label" for="cp_haveYou_32_1">dentures</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_haveYou_32_2" id="cp_haveYou_32_2" value="crowned/ veneered teeth"/>

<label class="cp_label" for="cp_haveYou_32_2">crowned/ veneered teeth</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_haveYou_32_3" id="cp_haveYou_32_3" value="pacemaker"/>

<label class="cp_label" for="cp_haveYou_32_3">pacemaker</label>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-4">

<label class="cp_label" for="cp_haveYou_34">34. How long will it take to travel home?:</label>

</div>

<div class="col-sm-8" style="margin-top: 15px;">

<input type="text" name="cp_haveYou_34" id="cp_haveYou_34" class="form-control" style="width: 100%;" placeholder="HH:MM" maxlength="5"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_haveYouPatientSig">Patient's signature</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_haveYouPatientSig" id="cp_haveYouPatientSig" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_haveYouAssessor">Assessor:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_haveYouAssessor" id="cp_haveYouAssessor" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_haveYouDate">Date</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_haveYouDate" id="cp_haveYouDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_haveYouAnaesthetist">Anaesthetist:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_haveYouAnaesthetist" id="cp_haveYouAnaesthetist" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_cvs">CVS:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_cvs" id="cp_cvs" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_GIT">GIT:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_GIT" id="cp_GIT" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_rs">RS:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_rs" id="cp_rs" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_cns">CNS:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_cns" id="cp_cns" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_GU">GU:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_GU" id="cp_GU" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_GS">B&#38;J:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_GS" id="cp_GS" class="form-control" style="width: 100%;"/>

</div>

</div>

</div>

<div class="cp_whiteBox">

<h2>For Professional use Only: PREOPERATIVE PHASE</h2>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_daySurgeryAdmittedDate">Admitted to Day Surgery Unit on:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_daySurgeryAdmittedDate" id="cp_daySurgeryAdmittedDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_daySurgeryAdmittedTime">Time:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_daySurgeryAdmittedTime" id="cp_daySurgeryAdmittedTime" class="form-control" style="width: 100%;" placeholder="HH:MM" maxlength="5"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_namedNurse2">Named Nurse:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_namedNurse2" id="cp_namedNurse2" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_nurseGrade2">Grade:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_nurseGrade2" id="cp_nurseGrade2" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_nbmTime">Nil by mouth from time:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_nbmTime" id="cp_nbmTime" class="form-control" style="width: 100%;" placeholder="HH:MM" maxlength="5"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_nbmDate">(date)</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_nbmDate" id="cp_nbmDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_menstrualDate">Date of last menstrual period</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_menstrualDate" id="cp_menstrualDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<p>Pain score is discussed and agreed acceptable level is recorded on post operative sheet:</p>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_changesIDd">Identified changes since assessment in Outpatient Clinic:</label>

<textarea class="form-control" name="cp_changesIDd" id="cp_changesIDd" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_preopDate">Date</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_preopDate" id="cp_preopDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_preopSig">Signature</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_preopSig" id="cp_preopSig" class="form-control" style="width: 100%;"/>

</div>

</div>

<p>Do you understand that after your operation and anaesthetic YOU SHOULD NOT:</p>

<ol>

<li>A) drive a motor car or any vehicle for 24 hours</li>

<li>B) operate machines or home appliances for 24 hours</li>

<li>C) drink alcohol for 24 hours</li>

<li>D) make important decisions for 24 hours</li>

<li>E) be left on your own without a responsible person for 24 hours</li>

</ol>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_assessDate">Assessment data rechecked by:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_assessDate" id="cp_assessDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_recentInfections">Any recent infections:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_recentInfections" id="cp_recentInfections" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Information confirmed by patient</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_infoConfirmed" id="cp_infoConfirmedYes" value="Yes">

<label class="form-check-label" for="cp_infoConfirmedYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_infoConfirmed" id="cp_infoConfirmedNo" value="No">

<label class="form-check-label" for="cp_infoConfirmedNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<p>If Yes</p>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_confirmSig">Signature:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_confirmSig" id="cp_confirmSig" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_confirmSigGrade">Grade:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_confirmSigGrade" id="cp_confirmSigGrade" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_actionTaken">Action taken:</label>

<textarea class="form-control" name="cp_actionTaken" id="cp_actionTaken" rows="3" style="width: 100%;"></textarea>

</div>

</div>

</div>

<div class="cp_whiteBox">

<h2>FOR PROFESSIONAL USE:</h2>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_namedNurse3">Named Nurse:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_namedNurse3" id="cp_namedNurse3" class="form-control" style="width: 100%;"/>

</div>

</div>

<p>Complete the relevant preoperative safety checks using the following checklist:-</p>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Consent form corresponds to patients understanding</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_1" id="cp_safetyChecks_1Yes" value="Yes">

<label class="form-check-label" for="cp_safetyChecks_1Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_1" id="cp_safetyChecks_1No" value="No">

<label class="form-check-label" for="cp_safetyChecks_1No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Consent form is signed</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_2" id="cp_safetyChecks_2Yes" value="Yes">

<label class="form-check-label" for="cp_safetyChecks_2Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_2" id="cp_safetyChecks_2Yes" value="No">

<label class="form-check-label" for="cp_safetyChecks_2Yes"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Identity band is correct and sited securely</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_3" id="cp_safetyChecks_3Yes" value="Yes">

<label class="form-check-label" for="cp_safetyChecks_3Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_3" id="cp_safetyChecks_3No" value="No">

<label class="form-check-label" for="cp_safetyChecks_3No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Operation site has been marked and shaved if necessary</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_4" id="cp_safetyChecks_4Yes" value="Yes">

<label class="form-check-label" for="cp_safetyChecks_4Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_4" id="cp_safetyChecks_4No" value="No">

<label class="form-check-label" for="cp_safetyChecks_4No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Make up is removed</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_5" id="cp_safetyChecks_5Yes" value="Yes">

<label class="form-check-label" for="cp_safetyChecks_5Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_5" id="cp_safetyChecks_5No" value="No">

<label class="form-check-label" for="cp_safetyChecks_5No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Jewellery is removed or taped</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_6" id="cp_safetyChecks_6Yes" value="Yes">

<label class="form-check-label" for="cp_safetyChecks_6Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_6" id="cp_safetyChecks_6No" value="No">

<label class="form-check-label" for="cp_safetyChecks_6No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Dentures, bridges, crowns, hairpiece removed/left in situ</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_7" id="cp_safetyChecks_7Yes" value="Yes">

<label class="form-check-label" for="cp_safetyChecks_7Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_7" id="cp_safetyChecks_7No" value="No">

<label class="form-check-label" for="cp_safetyChecks_7No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Property box is sealed and accompanies the patient</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_8" id="cp_safetyChecks_8Yes" value="Yes">

<label class="form-check-label" for="cp_safetyChecks_8Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_8" id="cp_safetyChecks_8No" value="No">

<label class="form-check-label" for="cp_safetyChecks_8No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>The patient understands the sequence of the days events and is given the information leaflets related to their operation</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_9" id="cp_safetyChecks_9Yes" value="Yes">

<label class="form-check-label" for="cp_safetyChecks_9Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_safetyChecks_9" id="cp_safetyChecks_9No" value="No">

<label class="form-check-label" for="cp_safetyChecks_9No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Uses:</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_uses_1" id="cp_uses_1" value="Contact lens"/>

<label class="cp_label" for="cp_uses_1">Contact lens</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_uses_2" id="cp_uses_2" value="hearing aid"/>

<label class="cp_label" for="cp_uses_2">hearing aid</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_uses_3" id="cp_uses_3" value="wig"/>

<label class="cp_label" for="cp_uses_3">wig</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_uses_4" id="cp_uses_4" value="prosthesis"/>

<label class="cp_label" for="cp_uses_4">prosthesis</label>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_usesSigned">Signed:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_usesSigned" id="cp_usesSigned" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_usesAction">If no to any of the above questions, action taken:</label>

<textarea class="form-control" name="cp_usesAction" id="cp_usesAction" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_usesSigned2">Signed:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_usesSigned2" id="cp_usesSigned2" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_usesCounterSigned">Counter signature:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_usesCounterSigned" id="cp_usesCounterSigned" class="form-control" style="width: 100%;"/>

</div>

</div>

</div>

<div class="cp_whiteBox">

<h2>Operation Summary</h2>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_operation">Operation:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_operation" id="cp_operation" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_surgeon">Surgeon(s):</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_surgeon" id="cp_surgeon" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_Anaesthetist">Anaesthetist(s):</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_Anaesthetist" id="cp_Anaesthetist" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Anaesth:</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_Anaesth" id="cp_AnaesthGA" value="GA">

<label class="form-check-label" for="cp_AnaesthGA"> GA</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_Anaesth" id="cp_AnaesthLA" value="LA">

<label class="form-check-label" for="cp_AnaesthLA"> LA</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_AnaesthetistsAssistant">Anaesthetists Assistant:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_AnaesthetistsAssistant" id="cp_AnaesthetistsAssistant" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_ScrubPerson">Scrub Person:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_ScrubPerson" id="cp_ScrubPerson" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_CirculatingPerson">Circulating Person:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_CirculatingPerson" id="cp_CirculatingPerson" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Sutures Used:</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_sutures" id="cp_suturesAbsorb" value="Absorbable">

<label class="form-check-label" for="cp_suturesAbsorb"> Absorbable</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_sutures" id="cp_suturesNon" value="non-absorbable">

<label class="form-check-label" for="cp_suturesNon"> non-absorbable</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_dressing">Dressing:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_dressing" id="cp_dressing" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_painControl">Local Anaesthetic for pain control:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_painControl" id="cp_painControl" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_sutureRemovalDate">Date for suture removal:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="date" name="cp_sutureRemovalDate" id="cp_sutureRemovalDate" class="form-control" placeholder="dd/mm/yyyy"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_outPatient">Out-patients appointment:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_outPatient" id="cp_outPatient" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_specimenSent">Specimen sent:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_specimenSent" id="cp_specimenSent" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_signed">Signed:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_signed" id="cp_signed" class="form-control" style="width: 100%;"/>

</div>

</div>

</div>

<div class="cp_whiteBox">

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_additionalComments">Additional information/comments:</label>

<textarea class="form-control" name="cp_additionalComments" id="cp_additionalComments" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_additionalCommentsSignature">Signature:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_additionalCommentsSignature" id="cp_additionalCommentsSignature" class="form-control" style="width: 100%;"/>

</div>

</div>

</div>

<div class="cp_whiteBox">

<h2>POST OPERATIVE PHASE</h2>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_recoveryArrival">Arrival in recovery at</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_recoveryArrival" id="cp_recoveryArrival" class="form-control" style="width: 100%;"/> hours

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Airway present:</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_airway" id="cp_airwayETT" value="ETT">

<label class="form-check-label" for="cp_airwayETT"> ETT</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_airway" id="cp_airwayNP" value="NP">

<label class="form-check-label" for="cp_airwayNP"> NP</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_airway" id="cp_airwayLM" value="LM">

<label class="form-check-label" for="cp_airwayLM"> LM</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_airway" id="cp_airwayGuedel" value="Guedel">

<label class="form-check-label" for="cp_airwayGuedel"> Guedel</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Oxygen:</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_Oxygen" id="cp_OxygenYes" value="Yes">

<label class="form-check-label" for="cp_OxygenYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_Oxygen" id="cp_OxygenNo" value="No">

<label class="form-check-label" for="cp_OxygenNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_OxygenPerMin">% per min:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_OxygenPerMin" id="cp_OxygenPerMin" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_OxygenPerMin">% per min:</label>

<textarea class="form-control" name="cp_OxygenPerMin" id="cp_OxygenPerMin" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<hr class="cp_separator"/>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_patientAwake">Patient awake at:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_patientAwake" id="cp_patientAwake" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_signed3">Signed:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_signed3" id="cp_signed3" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_grade3">Grade:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_grade3" id="cp_grade3" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_time">Time</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_time" id="cp_time" class="form-control" style="width: 100%;" placeholder="HH:MM" maxlength="5"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_Sao2">Sao2</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_Sao2" id="cp_Sao2" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_bp">BP</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_bp" id="cp_bp" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_T">T</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_T" id="cp_T" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_p">p</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_p" id="cp_p" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_R">R</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_R" id="cp_R" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_PainScore">Pain Score</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<select class="form-control" name="cp_PainScore" id="cp_PainScore">

<option value="--">Select</option>

<option value="0 - no pain at all">0 - no pain at all</option>

<option value="1 - mild pain ">1 - mild pain </option>

<option value="2 - moderate pain">2 - moderate pain</option>

<option value="3 - severe pain">3 - severe pain</option>

<option value="4 - unbearable pain">4 - unbearable pain</option>

</select>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_NauseaVomitinaScore">Nausea/vomitina score</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<select class="form-control" name="cp_NauseaVomitinaScore" id="cp_NauseaVomitinaScore">

<option value="--">Select</option>

<option value="1 - no nausea or vomiting">1 - no nausea or vomiting</option>

<option value="2 - mild nausea">2 - mild nausea</option>

<option value="3 - moderate nausea">3 - moderate nausea</option>

<option value="4 - vomited">4 - vomited</option>

<option value="5 - vomited more than twice">5 - vomited more than twice</option>

</select>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Dressing/wound checked:</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dressingChecked" id="cp_dressingCheckedclean" value="clean">

<label class="form-check-label" for="cp_dressingCheckedclean"> clean</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dressingChecked" id="cp_dressingCheckeddry" value="dry">

<label class="form-check-label" for="cp_dressingCheckeddry"> dry</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dressingChecked" id="cp_dressingCheckedintact" value="intact">

<label class="form-check-label" for="cp_dressingCheckedintact"> intact</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Pressure Areas Checked:</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_pressureHead" id="cp_pressureHead" value="head"/>

<label class="cp_label" for="cp_pressureHead">head</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_pressureears" id="cp_pressureears" value="ears"/>

<label class="cp_label" for="cp_pressureears">ears</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_pressureshoulders" id="cp_pressureshoulders" value="shoulders"/>

<label class="cp_label" for="cp_pressureshoulders">shoulders</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_pressureelbows" id="cp_pressureelbows" value="elbows"/>

<label class="cp_label" for="cp_pressureelbows">elbows</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_pressuresacrum" id="cp_pressuresacrum" value="sacrum"/>

<label class="cp_label" for="cp_pressuresacrum">sacrum</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_pressurehips" id="cp_pressurehips" value="hips"/>

<label class="cp_label" for="cp_pressurehips">hips</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_pressureheels" id="cp_pressureheels" value="heels"/>

<label class="cp_label" for="cp_pressureheels">heels</label>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_pressureankles" id="cp_pressureankles" value="ankles"/>

<label class="cp_label" for="cp_pressureankles">ankles</label>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_recoveryActions">Actions undertaken as a result of problems arising during recovery phase:</label>

<textarea class="form-control" name="cp_recoveryActions" id="cp_recoveryActions" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_signed4">Signed:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_signed4" id="cp_signed4" class="form-control" style="width: 100%;"/>

</div>

</div>

</div>

<div class="cp_whiteBox">

<h2>PRE DISCHARGE ASSESSMENT</h2>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>1. TPR and BP are within patient's preoperative limits</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_1" id="cp_preDischarge_1Yes" value="Yes">

<label class="form-check-label" for="cp_preDischarge_1Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_1" id="cp_preDischarge_1No" value="No">

<label class="form-check-label" for="cp_preDischarge_1No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>2. Wound/dressing checked</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_2" id="cp_preDischarge_2Yes" value="Yes">

<label class="form-check-label" for="cp_preDischarge_2Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_2" id="cp_preDischarge_2No" value="No">

<label class="form-check-label" for="cp_preDischarge_2No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>3. Does patient feel faint when mobilising?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_3" id="cp_preDischarge_3Yes" value="Yes">

<label class="form-check-label" for="cp_preDischarge_3Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_3" id="cp_preDischarge_3No" value="No">

<label class="form-check-label" for="cp_preDischarge_3No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>4. Has patient drunk at least one cup of fluid?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_4" id="cp_preDischarge_4Yes" value="Yes">

<label class="form-check-label" for="cp_preDischarge_4Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_4" id="cp_preDischarge_4No" value="No">

<label class="form-check-label" for="cp_preDischarge_4No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>5. Patient has passed urine</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_5" id="cp_preDischarge_5Yes" value="Yes">

<label class="form-check-label" for="cp_preDischarge_5Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_5" id="cp_preDischarge_5No" value="No">

<label class="form-check-label" for="cp_preDischarge_5No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_preDischarge_6">6. If urology patient, was urine?</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<select class="form-control" name="cp_preDischarge_6" id="cp_preDischarge_6">

<option value="--">Select</option>

<option value="clear">clear</option>

<option value="rosy">rosy</option>

<option value="dark">dark</option>

<option value="clots">clots</option>

</select>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>7. Does pain score exceed agreed limits?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_7" id="cp_preDischarge_7Yes" value="Yes">

<label class="form-check-label" for="cp_preDischarge_7Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_7" id="cp_preDischarge_7No" value="No">

<label class="form-check-label" for="cp_preDischarge_7No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>8. Does nausea/vomiting score exceed level 2?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_8" id="cp_preDischarge_8Yes" value="Yes">

<label class="form-check-label" for="cp_preDischarge_8Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_8" id="cp_preDischarge_8No" value="No">

<label class="form-check-label" for="cp_preDischarge_8No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>9. The IV Cannula has been removed and V.I.P. Score recorded?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_9" id="cp_preDischarge_9Yes" value="Yes">

<label class="form-check-label" for="cp_preDischarge_9Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_9" id="cp_preDischarge_9No" value="No">

<label class="form-check-label" for="cp_preDischarge_9No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>10. The ECG sticker has been removed</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_10" id="cp_preDischarge_10Yes" value="Yes">

<label class="form-check-label" for="cp_preDischarge_10Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_preDischarge_10" id="cp_preDischarge_10No" value="No">

<label class="form-check-label" for="cp_preDischarge_10No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_actionTaken2">Action taken following identified problem:</label>

<textarea class="form-control" name="cp_actionTaken2" id="cp_actionTaken2" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_actionTakenSig">Signature:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_actionTakenSig" id="cp_actionTakenSig" class="form-control" style="width: 100%;"/>

</div>

</div>

</div>

<div class="cp_whiteBox">

<h2>Requirements before discharge</h2>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>1. Patient understands relevance of the received analgesia/medication</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_1" id="cp_dischargeReq_1Yes" value="Yes">

<label class="form-check-label" for="cp_dischargeReq_1Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_1" id="cp_dischargeReq_1No" value="No">

<label class="form-check-label" for="cp_dischargeReq_1No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>2. Patient has received and understands relevant information leaflets</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_2" id="cp_dischargeReq_2Yes" value="Yes">

<label class="form-check-label" for="cp_dischargeReq_2Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_2" id="cp_dischargeReq_2No" value="No">

<label class="form-check-label" for="cp_dischargeReq_2No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_dischargeReq_2Specify">Please specify:</label>

<textarea class="form-control" name="cp_dischargeReq_2Specify" id="cp_dischargeReq_2Specify" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>3. Patient has received a copy of discharge letter</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_3" id="cp_dischargeReq_3Yes" value="Yes">

<label class="form-check-label" for="cp_dischargeReq_3Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_3" id="cp_dischargeReq_3No" value="No">

<label class="form-check-label" for="cp_dischargeReq_3No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>4. Time/date of follow-up appointment has been given</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_4" id="cp_dischargeReq_4Yes" value="Yes">

<label class="form-check-label" for="cp_dischargeReq_4Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_4" id="cp_dischargeReq_4No" value="No">

<label class="form-check-label" for="cp_dischargeReq_4No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>5. Patient has been given relveant 24 hour hospital contact numbers</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_5" id="cp_dischargeReq_5Yes" value="Yes">

<label class="form-check-label" for="cp_dischargeReq_5Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_5" id="cp_dischargeReq_5No" value="No">

<label class="form-check-label" for="cp_dischargeReq_5No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>6. The escort arrived to take the patient home</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_6" id="cp_dischargeReq_6Yes" value="Yes">

<label class="form-check-label" for="cp_dischargeReq_6Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_6" id="cp_dischargeReq_6No" value="No">

<label class="form-check-label" for="cp_dischargeReq_6No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>7. Patient feels adequately prepared for discharge</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_7" id="cp_dischargeReq_7Yes" value="Yes">

<label class="form-check-label" for="cp_dischargeReq_7Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_7" id="cp_dischargeReq_7No" value="No">

<label class="form-check-label" for="cp_dischargeReq_7No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>8. Discharge confirmed with medical staff/approved designated staff</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_8" id="cp_dischargeReq_8Yes" value="Yes">

<label class="form-check-label" for="cp_dischargeReq_8Yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dischargeReq_8" id="cp_dischargeReq_8No" value="No">

<label class="form-check-label" for="cp_dischargeReq_8No"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_actionTaken3">If no to any of the above questions - action taken:</label>

<textarea class="form-control" name="cp_actionTaken3" id="cp_actionTaken3" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_signed5">Signature:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_signed5" id="cp_signed5" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_sigApprovedStaff">Signature of approved designated staff:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_sigApprovedStaff" id="cp_sigApprovedStaff" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_dischargeAt">Discharged from unit at:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_dischargeAt" id="cp_dischargeAt" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_signed6">Signature:</label>

<textarea class="form-control" name="cp_signed6" id="cp_signed6" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_patientSig">Patient Signature:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_patientSig" id="cp_patientSig" class="form-control" style="width: 100%;"/>

</div>

</div>

</div>

</div>


Health Questionnaire Care Plan Template


Key Objectives

Provide patients with a digital health questionnaire care plan, assessing them for surgery.


Outcome measures

Equip patients with information and reduce clinical appointments


Current Baselines

All health questionnaires are on paper and sometimes forgotten by patients if sent prior to surgery or not shared with patients at all.

Example HTML code for Health questionnaire care plan template

<div class="form-inline">

<style media="screen">

a {word-wrap: break-word;}

.form-group {width: 100%; !important}

.cp_whiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; border-radius: 10px; border: 3px solid #014151;}

.cp_separator {height: 3px; background-color: #898989; margin-top: 5px; margin-bottom: 5px;}

</style>

<div class="cp_whiteBox">

<h2>Health Questionnaire - Assessing you for admission</h2>

<p>This questionnaire will provide us with an overall picture of your current state of health and will take around 30 minutes to complete. It's important that you provide us with detailed and honest information about your health and lifestyle choices.</p> <div class="row" style="margin-top: 15px;">

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_preferNameAddress" id="cp_preferNameAddress" class="form-control" style="width: 100%;"/>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_dob" id="cp_dob" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_escortNameNOK">Next of Kin Name:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_escortNameNOK" id="cp_escortNameNOK" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_escortNameNOKtel">Next of Kin Telephone No:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_escortNameNOKtel" id="cp_escortNameNOKtel" class="form-control" style="width: 100%;"/>

</div>

</div>

<hr class="cp_separator"/>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_GPname">GP Name:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_GPname" id="cp_GPname" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_GPaddress">Address:</label>

<textarea class="form-control" name="cp_GPaddress" id="cp_GPaddress" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_GPtel">Telephone No:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_GPtel" id="cp_GPtel" class="form-control" style="width: 100%;"/>

</div>

</div>

<hr class="cp_separator"/>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_StateName">If you are completing this Health Care Questionnaire on behalf of a patient, please can you state your name and relationship to the patient:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_StateName" id="cp_StateName" class="form-control" style="width: 100%;"/>

</div>

</div>

<hr class="cp_separator"/>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_dataStateProcedure">Please state what procedure/surgery you are attending the Hospital for?</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_dataStateProcedure" id="cp_dataStateProcedure" class="form-control" style="width: 100%;"/>

</div>

</div>

</div>

<div class="cp_whiteBox">

<h2>PATIENT TO COMPLETE:</h2>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Please confirm you have read and understand the Admission Information located in the <a href="/library/manageLibrary.action" target="_blank">Library</a> that contains all the relevant information you should need before, during and after your stay in hospital.</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q1" id="cp_q1_yes" value="Yes">

<label class="form-check-label" for="cp_q1_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q1" id="cp_q1_no" value="No">

<label class="form-check-label" for="cp_q1_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Are you double vaccinated against COVID 19? (Double vaccinated is defined as receiving 2 doses of a COVID-19 vaccine and does not include any booster vaccinations.)</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_covidinjectionRequired" id="cp_covidinjectionRequiredYes" value="Yes">

<label class="form-check-label" for="cp_covidinjectionRequiredYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_covidinjectionRequired" id="cp_covidinjectionRequiredNo" value="No">

<label class="form-check-label" for="cp_covidinjectionRequiredNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Will you need an interpreter available on the day of your admission?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_intepreterRequired" id="cp_intepreterRequiredYes" value="Yes">

<label class="form-check-label" for="cp_intepreterRequiredYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_intepreterRequired" id="cp_intepreterRequiredNo" value="No">

<label class="form-check-label" for="cp_intepreterRequiredNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have any Mental Capacity issues that would mean you require a carer to escort you on the day of your admission?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q2" id="cp_q2_yes" value="Yes">

<label class="form-check-label" for="cp_q2_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q2" id="cp_q2_no" value="No">

<label class="form-check-label" for="cp_q2_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Will you have a responsible/capable adult at home to look after you for the first 24 hours following your operation/procedure?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q4" id="cp_q4_yes" value="Yes">

<label class="form-check-label" for="cp_q4_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q4" id="cp_q4_no" value="No">

<label class="form-check-label" for="cp_q4_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Will you have access to a telephone for the first 24 hours following your operation/ procedure?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q3" id="cp_q3_yes" value="Yes">

<label class="form-check-label" for="cp_q3_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q3" id="cp_q3_no" value="No">

<label class="form-check-label" for="cp_q3_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Will you be able to provide your own transport WITH a responsible/capable adult escorting you if discharged within 24 hours following your operation?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q5" id="cp_q5_yes" value="Yes">

<label class="form-check-label" for="cp_q5_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q5" id="cp_q5_no" value="No">

<label class="form-check-label" for="cp_q5_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you had any previous surgery/procedures?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q6" id="cp_q6_yes" value="Yes">

<label class="form-check-label" for="cp_q6_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q6" id="cp_q6_no" value="No">

<label class="form-check-label" for="cp_q6_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_procedures">If yes please list the surgery/procedure and date.</label>

<textarea class="form-control" name="cp_procedures" id="cp_procedures" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have any medical conditions e.g Diabetes, Asthma, COPD, Hypothyroid?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q7" id="cp_q7_yes" value="Yes">

<label class="form-check-label" for="cp_q7_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q7" id="cp_q7_no" value="No">

<label class="form-check-label" for="cp_q7_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_medicalCondition">If yes please list your medical condition:</label>

<textarea class="form-control" name="cp_medicalCondition" id="cp_medicalCondition" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have a specific allergy to any of the following? Latex, Nickel, any metal, Gentamicin, eggs, nuts, anaesthetic medications, Iodine or CT contrast.</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q8" id="cp_q8_yes" value="Yes">

<label class="form-check-label" for="cp_q8_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q8" id="cp_q8_no" value="No">

<label class="form-check-label" for="cp_q8_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have any allergies other than those listed above?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_otherAllergies" id="cp_otherAllergiesYes" value="Yes">

<label class="form-check-label" for="cp_otherAllergiesYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_otherAllergies" id="cp_otherAllergiesNo" value="No">

<label class="form-check-label" for="cp_otherAllergiesNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_allergiesList">If yes please list your allergies here:</label>

<textarea class="form-control" name="cp_allergiesList" id="cp_allergiesList" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have speech/vocal problems or needs?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q10" id="cp_q10_yes" value="Yes">

<label class="form-check-label" for="cp_q10_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q10" id="cp_q10_no" value="No">

<label class="form-check-label" for="cp_q10_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Are you fully independent with mobility, and able to dress and undress yourself?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q11" id="cp_q11_yes" value="Yes">

<label class="form-check-label" for="cp_q11_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q11" id="cp_q11_no" value="No">

<label class="form-check-label" for="cp_q11_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever had a blood transfusion?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_bloodTransfusion" id="cp_bloodTransfusionYes" value="Yes">

<label class="form-check-label" for="cp_bloodTransfusionYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_bloodTransfusion" id="cp_bloodTransfusionNo" value="No">

<label class="form-check-label" for="cp_bloodTransfusionNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>If yes, did you have any problems because of the blood transfusion?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q12" id="cp_q12_yes" value="Yes">

<label class="form-check-label" for="cp_q12_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q12" id="cp_q12_no" value="No">

<label class="form-check-label" for="cp_q12_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>If you have had a blood transfusion, was it within the last 90 days?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q13" id="cp_q13_yes" value="Yes">

<label class="form-check-label" for="cp_q13_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q13" id="cp_q13_no" value="No">

<label class="form-check-label" for="cp_q13_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever suffered with chest pain and/ or diagnosed with angina?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q14" id="cp_q14_yes" value="Yes">

<label class="form-check-label" for="cp_q14_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q14" id="cp_q14_no" value="No">

<label class="form-check-label" for="cp_q14_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_chestPain">If yes, please state when:</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_chestPain" id="cp_chestPain" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever been diagnosed with heart failure?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q15" id="cp_q15_yes" value="Yes">

<label class="form-check-label" for="cp_q15_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q15" id="cp_q15_no" value="No">

<label class="form-check-label" for="cp_q15_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever been referred to a heart specialist?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q16" id="cp_q16_yes" value="Yes">

<label class="form-check-label" for="cp_q16_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q16" id="cp_q16_no" value="No">

<label class="form-check-label" for="cp_q16_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_specialistHospital">If yes, Please state the specialist/hospital you were referred to and when:</label>

<textarea class="form-control" name="cp_specialistHospital" id="cp_specialistHospital" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever had a heart attack?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q17" id="cp_q17_yes" value="Yes">

<label class="form-check-label" for="cp_q17_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q17" id="cp_q17_no" value="No">

<label class="form-check-label" for="cp_q17_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have heart stents in place?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q18" id="cp_q18_yes" value="Yes">

<label class="form-check-label" for="cp_q18_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q18" id="cp_q18_no" value="No">

<label class="form-check-label" for="cp_q18_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever been diagnosed with a heart murmur or heart valve problems?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q19" id="cp_q19_yes" value="Yes">

<label class="form-check-label" for="cp_q19_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q19" id="cp_q19_no" value="No">

<label class="form-check-label" for="cp_q19_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever suffered with a very fast, slow or irregular heartbeat, or have you been diagnosed with AF (Atrial Fibrilation)?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q20" id="cp_q20_yes" value="Yes">

<label class="form-check-label" for="cp_q20_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q20" id="cp_q20_no" value="No">

<label class="form-check-label" for="cp_q20_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have high blood pressure, high cholesterol, or are you prescribed blood pressure medications?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q22" id="cp_q22_yes" value="Yes">

<label class="form-check-label" for="cp_q22_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q22" id="cp_q22_no" value="No">

<label class="form-check-label" for="cp_q22_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you suffer from dizziness or fainting?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q23" id="cp_q23_yes" value="Yes">

<label class="form-check-label" for="cp_q23_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q23" id="cp_q23_no" value="No">

<label class="form-check-label" for="cp_q23_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have a pacemaker or internal defibrillator in place?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q24" id="cp_q24_yes" value="Yes">

<label class="form-check-label" for="cp_q24_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q24" id="cp_q24_no" value="No">

<label class="form-check-label" for="cp_q24_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_24_hospital">If yes, in which hospital was it inserted and when?</label>

<textarea class="form-control" name="cp_24_hospital" id="cp_24_hospital" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever been diagnosed with any aneurysm (a diagnosed bulge or ballooning of blood vessels)?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q26" id="cp_q26_yes" value="Yes">

<label class="form-check-label" for="cp_q26_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q26" id="cp_q26_no" value="No">

<label class="form-check-label" for="cp_q26_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_26_Hospital">If yes, in which hospital was it diagnosed and when?</label>

<textarea class="form-control" name="cp_26_Hospital" id="cp_26_Hospital" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever been diagnosed with Peripheral Vascular Disease or any other blood circulation disorders?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q27" id="cp_q27_yes" value="Yes">

<label class="form-check-label" for="cp_q27_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q27" id="cp_q27_no" value="No">

<label class="form-check-label" for="cp_q27_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever had a stroke/mini stroke or TIA?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q28" id="cp_q28_yes" value="Yes">

<label class="form-check-label" for="cp_q28_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q28" id="cp_q28_no" value="No">

<label class="form-check-label" for="cp_q28_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_28_when">If yes, please state when:</label>

<textarea class="form-control" name="cp_28_when" id="cp_28_when" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you suffer from any lung disease or other breathing problems such as asthma, bronchitis, COPD or TB?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q29" id="cp_q29_yes" value="Yes">

<label class="form-check-label" for="cp_q29_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q29" id="cp_q29_no" value="No">

<label class="form-check-label" for="cp_q29_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you suffer with or are undergoing investigations into sleep apnoea?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q30" id="cp_q30_yes" value="Yes">

<label class="form-check-label" for="cp_q30_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q30" id="cp_q30_no" value="No">

<label class="form-check-label" for="cp_q30_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you use a CPAP machine?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q31" id="cp_q31_yes" value="Yes">

<label class="form-check-label" for="cp_q31_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q31" id="cp_q31_no" value="No">

<label class="form-check-label" for="cp_q31_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Are you breathless at rest or on minimal movement?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q33" id="cp_q33_yes" value="Yes">

<label class="form-check-label" for="cp_q33_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q33" id="cp_q33_no" value="No">

<label class="form-check-label" for="cp_q33_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Can you climb one flight of stairs without breathlessness or chestpain?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q34" id="cp_q34_yes" value="Yes">

<label class="form-check-label" for="cp_q34_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q34" id="cp_q34_no" value="No">

<label class="form-check-label" for="cp_q34_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Can you walk up to 100 yards (or 100 meters) without breathlessness or chestpain?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q35" id="cp_q35_yes" value="Yes">

<label class="form-check-label" for="cp_q35_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q35" id="cp_q35_no" value="No">

<label class="form-check-label" for="cp_q35_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>If you lie down without a pillow do you become breathless and/or experience acid reflux?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q36" id="cp_q36_yes" value="Yes">

<label class="form-check-label" for="cp_q36_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q36" id="cp_q36_no" value="No">

<label class="form-check-label" for="cp_q36_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you use a nebulizer or oxygen at home?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q37" id="cp_q37_yes" value="Yes">

<label class="form-check-label" for="cp_q37_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q37" id="cp_q37_no" value="No">

<label class="form-check-label" for="cp_q37_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Within the last 6 weeks, have you suffered or are you currently suffering with a chest infection, cough, cold, or flu or are you producing phlegm?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_coldFlu" id="cp_coldFluYes" value="Yes">

<label class="form-check-label" for="cp_coldFluyes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_coldFlu" id="cp_coldFluNo" value="No">

<label class="form-check-label" for="cp_coldFluNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you smoke, or have you ever smoked?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q38" id="cp_q38_yes" value="Yes">

<label class="form-check-label" for="cp_q38_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q38" id="cp_q38_no" value="No">

<label class="form-check-label" for="cp_q38_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have any restrictions moving your neck or opening your mouth?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q39" id="cp_q39_yes" value="Yes">

<label class="form-check-label" for="cp_q39_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q39" id="cp_q39_no" value="No">

<label class="form-check-label" for="cp_q39_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have any problems with your airway or had surgery on your airway that may cause intubation problems?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q40" id="cp_q40_yes" value="Yes">

<label class="form-check-label" for="cp_q40_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q40" id="cp_q40_no" value="No">

<label class="form-check-label" for="cp_q40_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you or any of your family ever had a reaction to or complication with a general or local anaesthetic?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q41" id="cp_q41_yes" value="Yes">

<label class="form-check-label" for="cp_q41_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q41" id="cp_q41_no" value="No">

<label class="form-check-label" for="cp_q41_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have dentures or crowned or veneered teeth?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dentures" id="cp_denturesYes" value="Yes">

<label class="form-check-label" for="cp_denturesYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_dentures" id="cp_denturesNo" value="No">

<label class="form-check-label" for="cp_denturesNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have any loose, damaged or chipped teeth?

</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_chippedTeeth" id="cp_chippedTeethYes" value="Yes">

<label class="form-check-label" for="cp_chippedTeethYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_chippedTeeth" id="cp_chippedTeethNo" value="No">

<label class="form-check-label" for="cp_chippedTeethNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you suffered with nausea and or vomiting immediately after a procedure/ surgery?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q42" id="cp_q42_yes" value="Yes">

<label class="form-check-label" for="cp_q42_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q42" id="cp_q42_no" value="No">

<label class="form-check-label" for="cp_q42_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have fits e.g Epilepsy?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q45" id="cp_q45_yes" value="Yes">

<label class="form-check-label" for="cp_q45_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q45" id="cp_q45_no" value="No">

<label class="form-check-label" for="cp_q45_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have any neurological problems (e.g. Multiple Sclerosis, Parkinsons, Muscular Dystrophy, Motor Neurone Disease, Huntington's Disease)?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q46" id="cp_q46_yes" value="Yes">

<label class="form-check-label" for="cp_q46_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q46" id="cp_q46_no" value="No">

<label class="form-check-label" for="cp_q46_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have any mental health conditions i.e. psychiatric disorders, depression, anxiety, self-harm?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q47" id="cp_q47_yes" value="Yes">

<label class="form-check-label" for="cp_q47_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q47" id="cp_q47_no" value="No">

<label class="form-check-label" for="cp_q47_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever suffered with any liver problems e.g. Hepatitis?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q48" id="cp_q48_yes" value="Yes">

<label class="form-check-label" for="cp_q48_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q48" id="cp_q48_no" value="No">

<label class="form-check-label" for="cp_q48_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Are you visibly yellow, or have been informed by a health professional that you have jaundice?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_jaundice" id="cp_jaundiceYes" value="Yes">

<label class="form-check-label" for="cp_jaundiceYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_jaundice" id="cp_jaundiceNo" value="No">

<label class="form-check-label" for="cp_jaundiceNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you suffer with Indigestion or heartburn problems, or have a hiatus hernia or suffer from acid reflux?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q49" id="cp_q49_yes" value="Yes">

<label class="form-check-label" for="cp_q49_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q49" id="cp_q49_no" value="No">

<label class="form-check-label" for="cp_q49_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have swallowing problems?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q50" id="cp_q50_yes" value="Yes">

<label class="form-check-label" for="cp_q50_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q50" id="cp_q50_no" value="No">

<label class="form-check-label" for="cp_q50_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you been diagnosed with grade 3 or 4 Renal Failure, or you receive Renal Dialysis?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q51" id="cp_q51_yes" value="Yes">

<label class="form-check-label" for="cp_q51_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q51" id="cp_q51_no" value="No">

<label class="form-check-label" for="cp_q51_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have anaemia or other blood conditions e.g. sickle-cell, thalasaemia?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q52" id="cp_q52_yes" value="Yes">

<label class="form-check-label" for="cp_q52_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q52" id="cp_q52_no" value="No">

<label class="form-check-label" for="cp_q52_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you been diagnosed with an immune-suppressing condition e.g HIV ?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_hiv" id="cp_hivYes" value="Yes">

<label class="form-check-label" for="cp_hivYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_hiv" id="cp_hivNo" value="No">

<label class="form-check-label" for="cp_hivNo"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you suffer with excessive bleeding or bruising, or suffer from any clotting disorders e.g Haemophilia, Von Willibrand's disease or factor deficiencies?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q53" id="cp_q53_yes" value="Yes">

<label class="form-check-label" for="cp_q53_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q53" id="cp_q53_no" value="No">

<label class="form-check-label" for="cp_q53_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you take blood thinning medication?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q54" id="cp_q54_yes" value="Yes">

<label class="form-check-label" for="cp_q54_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q54" id="cp_q54_no" value="No">

<label class="form-check-label" for="cp_q54_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have arthritis for which you take prescribed medication?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q55" id="cp_q55_yes" value="Yes">

<label class="form-check-label" for="cp_q55_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q55" id="cp_q55_no" value="No">

<label class="form-check-label" for="cp_q55_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have any muscle disease, or any hereditary muscle disease e.g Myasthenia Gravis?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q58" id="cp_q58_yes" value="Yes">

<label class="form-check-label" for="cp_q58_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q58" id="cp_q58_no" value="No">

<label class="form-check-label" for="cp_q58_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have diabetes, or are you currently undergoing investigation for diabetes?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q59" id="cp_q59_yes" value="Yes">

<label class="form-check-label" for="cp_q59_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q59" id="cp_q59_no" value="No">

<label class="form-check-label" for="cp_q59_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you suffer from any thyroid problems?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q60" id="cp_q60_yes" value="Yes">

<label class="form-check-label" for="cp_q60_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q60" id="cp_q60_no" value="No">

<label class="form-check-label" for="cp_q60_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you take any prescription medication that has NOT been prescribed by your GP?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q63" id="cp_q63_yes" value="Yes">

<label class="form-check-label" for="cp_q63_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q63" id="cp_q63_no" value="No">

<label class="form-check-label" for="cp_q63_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_nonPrescribedMeds">If yes, please list:</label>

<textarea class="form-control" name="cp_nonPrescribedMeds" id="cp_nonPrescribedMeds" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you take any over the counter medication/herbal remedies?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q64" id="cp_q64_yes" value="Yes">

<label class="form-check-label" for="cp_q64_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q64" id="cp_q64_no" value="No">

<label class="form-check-label" for="cp_q64_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_q64_herbalList">If yes, please list:</label>

<textarea class="form-control" name="cp_q64_herbalList" id="cp_q64_herbalList" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you take any recreational drugs e.g. Cocaine, Heroin, Cannabis?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q65" id="cp_q65_yes" value="Yes">

<label class="form-check-label" for="cp_q65_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q65" id="cp_q65_no" value="No">

<label class="form-check-label" for="cp_q65_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you drink more than 20 units of alcohol a week? One unit is equal to a half a pint of lager/beer, one 125ml glass of wine or one 25ml measure of spirit</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q66" id="cp_q66_yes" value="Yes">

<label class="form-check-label" for="cp_q66_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q66" id="cp_q66_no" value="No">

<label class="form-check-label" for="cp_q66_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Are you or could you be pregnant?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q67" id="cp_q67_yes" value="Yes">

<label class="form-check-label" for="cp_q67_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q67" id="cp_q67_no" value="No">

<label class="form-check-label" for="cp_q67_no"> No</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q67" id="cp_q67_dk" value="Don't Know">

<label class="form-check-label" for="cp_q67_dk"> Don't Know</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Are you taking the contraceptive pill?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q68" id="cp_q68_yes" value="Yes">

<label class="form-check-label" for="cp_q68_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q68" id="cp_q68_no" value="No">

<label class="form-check-label" for="cp_q68_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you have a contraceptive device or contraceptive implant in place?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q69" id="cp_q69_yes" value="Yes">

<label class="form-check-label" for="cp_q69_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q69" id="cp_q69_no" value="No">

<label class="form-check-label" for="cp_q69_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Are you taking hormone replacement medication e.g. HRT?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q70" id="cp_q70_yes" value="Yes">

<label class="form-check-label" for="cp_q70_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q70" id="cp_q70_no" value="No">

<label class="form-check-label" for="cp_q70_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>If you are an ORTHOPAEDIC patient only, do you have any skin breaks, sores or cuts, including fungal nail infection?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q71" id="cp_q71_yes" value="Yes">

<label class="form-check-label" for="cp_q71_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q71" id="cp_q71_no" value="No">

<label class="form-check-label" for="cp_q71_no"> No</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q71" id="cp_q71_na" value="N/A">

<label class="form-check-label" for="cp_q71_na"> N/A</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>If you are a NEUROSURGERY patient only, are you pain free?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_neurosurgery" id="cp_neurosurgeryYes" value="Yes">

<label class="form-check-label" for="cp_neurosurgeryYes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_neurosurgery" id="cp_neurosurgeryNo" value="No">

<label class="form-check-label" for="cp_neurosurgeryNo"> No</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_neurosurgery" id="cp_neurosurgeryNa" value="N/A">

<label class="form-check-label" for="cp_neurosurgeryNa"> N/A</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you been diagnosed with Lymphoedema?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q72" id="cp_q72_yes" value="Yes">

<label class="form-check-label" for="cp_q72_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q72" id="cp_q72_no" value="No">

<label class="form-check-label" for="cp_q72_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you been diagnosed as a carrier of Clostridium Dificile?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q73" id="cp_q73_yes" value="Yes">

<label class="form-check-label" for="cp_q73_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q73" id="cp_q73_no" value="No">

<label class="form-check-label" for="cp_q73_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you ever been notified that you are at increased risk of CJD or vCJD for public health purposes?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q74" id="cp_q74_yes" value="Yes">

<label class="form-check-label" for="cp_q74_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q74" id="cp_q74_no" value="No">

<label class="form-check-label" for="cp_q74_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>In the last 12 months, have you been an inpatient in a hospital within another Trust or abroad?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q75" id="cp_q75_yes" value="Yes">

<label class="form-check-label" for="cp_q75_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q75" id="cp_q75_no" value="No">

<label class="form-check-label" for="cp_q75_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you been informed by a Health Professional as being positive for CPE or CPO? (Carbapenamase Producing Enterobacteriaceae, or Carbapenamase Producing Organisms)</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q76" id="cp_q76_yes" value="Yes">

<label class="form-check-label" for="cp_q76_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q76" id="cp_q76_no" value="No">

<label class="form-check-label" for="cp_q76_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Have you been informed by a Health Professional as being colonised with or infected by MRSA? (Meticillin Resistant Staphylococcus Aureus)</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q77" id="cp_q77_yes" value="Yes">

<label class="form-check-label" for="cp_q77_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q77" id="cp_q77_no" value="No">

<label class="form-check-label" for="cp_q77_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Is there anything not already asked that you think may be relevant to your health or your planned surgery?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q78" id="cp_q78_yes" value="Yes">

<label class="form-check-label" for="cp_q78_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q78" id="cp_q78_no" value="No">

<label class="form-check-label" for="cp_q78_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_q78_details">If yes, please give details:</label>

<textarea class="form-control" name="cp_q78_details" id="cp_q78_details" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<p>Do you still want to go ahead with your planned surgery?</p>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q79" id="cp_q79_yes" value="Yes">

<label class="form-check-label" for="cp_q79_yes"> Yes</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q79" id="cp_q79_no" value="No">

<label class="form-check-label" for="cp_q79_no"> No</label>

</input>

</div>

</div>

</div>

</div>

<div class="row">

<div class="col-sm-12">

<hr class="cp_separator"/>

<p>Thank you for completing this questionnaire, once you are happy all questions have been completed please use this button to go to the bottom of the plan and press save </p>

<p><a href="#fileUploadForm_save" class="btn arrow btn-primary" title="Goto the Save button" alt="Click here to go to the save button" style="margin-top:15px; margin-bottom:15px;">Goto the Save button</a></p>

</div>

</div>

</div>

<div class="cp_whiteBox">

<h2>For Clinical Use Only:</h2>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_profAmendments">Care plan evaluation</label>

<textarea class="form-control" name="cp_profAmendments" id="cp_profAmendments" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_patientGeneralApperance">Patients general appearance:</label>

<textarea class="form-control" name="cp_patientGeneralApperance" id="cp_patientGeneralApperance" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_bp">BP</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_bp" id="cp_bp" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_pulse">Pulse (RPM)</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_pulse" id="cp_pulse" class="form-control" style="width: 100%;"/>

<div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_pulseType" id="cp_pulseType1" value="Regular">

<label class="form-check-label" for="cp_pulseType1"> *Regular</label>

</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_pulseType" id="cp_pulseType2" value="Irregular">

<label class="form-check-label" for="cp_pulseType2"> *Irregular</label>

</input>

</div>

</div>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-12">

<label class="cp_label" for="cp_respRate">Resp Rate (rpm)</label>

<textarea class="form-control" name="cp_respRate" id="cp_respRate" rows="3" style="width: 100%;"></textarea>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_Temp">Temp (degrees C)</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_Temp" id="cp_Temp" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_sa02">Oxygen Saturations (%)</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_sa02" id="cp_sa02" class="form-control" style="width: 100%;"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_height">Height (m/ cm)</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_height" id="cp_height" class="form-control" style="width: 100%;" placeholder="m/cm"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_weight">Weight (kg)</label>

</div>

<div class="col-sm-6" style="margin-top: 15px;">

<input type="text" name="cp_weight" id="cp_weight" class="form-control" style="width: 100%;" placeholder="kg"/>

</div>

</div>

<div class="row" style="margin-top: 15px;">

<div class="col-sm-6">

<label class="cp_label" for="cp_bmi">BMI</label>