New Patient Form

Dr Chahaya Gauci — Colorectal & General Surgeon

Before your appointment

This form takes about 10–15 minutes. Your answers save automatically on this device, so you can stop and come back. Nothing is sent until you press Finish.

How your information is used

Dr Chahaya Gauci (Colorectal & General Surgeon, Suite 4, 29–33 Orlando Street, Coffs Harbour NSW) is collecting this information to prepare for your consultation and, if needed, your operation. It will form part of your medical record, stored securely by the practice in line with the Privacy Act 1988 (Cth) and NSW health records law. It is only shared with people involved in your care (for example your GP, anaesthetist or hospital). You can ask to see or correct your record at any time by contacting the rooms on (02) 6651 6211. You may skip any question you prefer not to answer.

I understand and agree to this information being collected and added to my medical record.

Please tick the box above to continue.

Who is filling this in?

I am the patient I'm completing this on behalf of the patient

Your name and relationship to the patient

Your details

First name

Family name

Please enter your name.

Date of birth

Please enter your date of birth.

Sex recorded at birth

Female Male Other / prefer not to say

Gender (if different, optional) Medicare card number (10 digits)

Number next to your name (IRN)

Medicare expiry

Private health fund & member number (if any) DVA or pension/concession card (if any) Best phone number Email (optional) Home address

Suburb

Postcode

Your GP and contacts

Referring GP or doctor GP practice name / town Date on your referral letter (if known)

Emergency contact / next of kin

Name

Relationship

Their phone number

Background

Preferred language Do you need an interpreter?

No Yes

Are you of Aboriginal or Torres Strait Islander origin?

No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander Prefer not to say

What brings you in?

Tick everything that applies — you'll only be asked follow-up questions about what you tick.

Bleeding from the bottom A change in bowel habit looser, harder, more or less often than usual for you Tummy (abdominal) pain Pain or a lump at the anus Trouble holding on / leakage from the bowel Constipation Something coming down / prolapse Losing weight without trying An abnormal scan, blood test or scope result Follow-up of a known cancer or polyps Hernia Pilonidal sinus / abscess (near the tailbone) Something else

Please describe

How long has this been going on? In your own words, tell me about the problem (optional)

About the bleeding

What colour is the blood?

Bright red Dark red Black or tarry

Where do you see it? (tick all)

On the toilet paper In the toilet pan Mixed in with the stool

About your bowel habit

What do your stools usually look like now? (Bristol chart)

Type 1 Separate hard lumps, like nuts Type 2 Sausage-shaped but lumpy Type 3 Like a sausage with cracks on the surface Type 4 Smooth and soft, like a sausage or snake Type 5 Soft blobs with clear edges Type 6 Mushy with ragged edges Type 7 Entirely liquid

How many times do you open your bowels per day (roughly)? Do you get urgency (having to rush)?

NoYes

Do you have to get up at night to open your bowels?

NoYes

About the leakage

What do you have trouble holding on to? (tick all)

Wind Liquid stool Solid stool

Do you wear a pad for this?

NoYes

About the prolapse

Does it go back in?

Goes back in by itself I push it back in It stays out

Do you need to press around the area or use a finger to help empty your bowels?

NoYes

Your medical history

Tick any conditions you have now or have had before.

High blood pressure Heart disease, angina or heart attack Irregular heartbeat (e.g. atrial fibrillation) Heart failure Heart valve problem Stroke or mini-stroke (TIA) Asthma or COPD / emphysema Sleep apnoea Diabetes Thyroid problem Kidney disease Liver disease Crohn's disease or ulcerative colitis Cancer (now or in the past) A bleeding or clotting disorder A blood clot in the leg (DVT) or lung (PE) A mental health condition e.g. depression, anxiety Reflux or stomach ulcer

Do you use a CPAP machine?

YesNo

Which type of diabetes?

Type 1Type 2Not sure

How is it managed?

Diet onlyTabletsInsulinBoth

Most recent HbA1c (if you know it)

What type of cancer, and when?

Any other medical conditions?

Operations and procedures

Have you had any operations before?

No Yes

Did any of these involve your tummy (abdomen), pelvis or bowel/anus?

NoYes

Camera tests (endoscopy)

Have you had a colonoscopy or gastroscopy before?

No Yes

When, and what was found (if you know)?

Anaesthetics

Have you or a blood relative ever had a problem with an anaesthetic? e.g. malignant hyperthermia, severe sickness afterwards, difficult airway/breathing tube, being aware during surgery

No Yes Not sure

Please describe (who and what happened)

Your medications

Include everything — prescriptions, over-the-counter medicines, vitamins and herbal supplements. A photo of your medication list at your appointment also helps.

Do you take any regular medications?

No Yes

Important safety questions

These medicines matter a lot around surgery, so I ask about them separately.

Do you take a blood thinner or anything for your blood? e.g. aspirin, clopidogrel (Plavix/Iscover), warfarin, apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), ticagrelor (Brilinta)

No Yes Not sure

Which one(s)?

Aspirin (Cartia, Astrix) Clopidogrel (Plavix, Iscover) Ticagrelor (Brilinta) Prasugrel (Effient) Dipyridamole (Persantin, Asasantin) Warfarin (Coumadin, Marevan) Apixaban (Eliquis) Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Enoxaparin (Clexane) / heparin injections Other / not sure of the name

Most recent INR (if known)

Why do you take it, and who prescribed it? (e.g. heart stent 2021 — cardiologist)

Do you take any diabetes medicines or injections?

No Yes

Which of these? (tick all)

Insulin Metformin (Diabex, Diaformin) A tablet ending in "-gliflozin" Jardiance (empagliflozin), Forxiga (dapagliflozin), Steglatro A weekly/daily injection (not insulin) or weight-loss injection Ozempic, Wegovy, Trulicity, Mounjaro, Saxenda, Victoza Gliclazide (Diamicron) or glimepiride A tablet ending in "-gliptin" Januvia, Trajenta, Galvus Other / combination tablet

Insulin type and doses

Do you take steroids, immune-suppressing medicines, or biologic injections/infusions? e.g. prednisone, methotrexate, azathioprine, infliximab, adalimumab (Humira)

No Yes

Name, dose and how long you've been on it

Do you take blood pressure medicines?

No Yes

Is one of them an "ACE inhibitor" or "sartan"? names ending in "-pril" (perindopril, ramipril) or "-sartan" (irbesartan, candesartan)

YesNoNot sure

Allergies and reactions

Do you have any allergies or bad reactions to medicines or other things?

No known allergies Yes

Do any of these apply? (tick all)

An antibiotic Latex (rubber gloves, balloons) An anaesthetic drug X-ray contrast / dye Sticky dressings or tapes A food

Smoking, alcohol and body size

Smoking

Never smoked Used to smoke, quit I currently smoke Vape only

Year you quit

Years you smoked

Cigarettes per day (back then)

Cigarettes per day

For how many years?

Stopping smoking — even a few weeks before surgery — meaningfully lowers the risk of wound and breathing complications. Quitline: 13 7848. We can help.

Alcohol

How often do you have a drink containing alcohol?

Never Monthly or less 2–4 times a month 2–3 times a week 4 or more times a week

On a day when you drink, how many standard drinks do you have? a standard drink = a middy of beer, a small (100ml) glass of wine, or one nip of spirits

1 or 2 3 or 4 5 or 6 7 to 9 10 or more

How often do you have 6 or more standard drinks on one occasion?

Never Less than monthly Monthly Weekly Daily or almost daily

Do you use any recreational drugs? (optional — asked only because some interact with anaesthetics; this stays confidential)

Height and weight

Height (cm)

Weight (kg)

Fitness and home situation

This helps with planning your anaesthetic and your recovery at home.

Can you climb 2 flights of stairs without stopping?

YesNo

Can you walk 500 metres on flat ground without stopping?

YesNo

Have you had a fall in the last 12 months?

NoYes

Do you use a walking aid?

NoStickFrameWheelchair

Do you live alone?

NoYes

Do you have any home supports? (tick all)

Family or friends who can help Home care services / package I have a carer I'm a carer for someone else None of these

Your occupation (or previous, if retired — helps with return-to-work and lifting advice)

Your family's health

"Blood relatives" means parents, brothers and sisters, children, grandparents, aunts and uncles.

Has a blood relative had any of these? (tick all)

Bowel cancer Bowel polyps Another type of cancer Crohn's disease or ulcerative colitis A bleeding disorder A serious anaesthetic reaction None of these / not sure

Who had bowel cancer, and roughly how old were they when it was found?

What type of cancer, who, and at what age?

Almost done

Anything else you'd like me to know before your appointment? (optional)

When you press Finish, a summary is created for Dr Gauci to review at your appointment. Please check your name and date of birth are correct first.

Please go back and complete your name, date of birth and consent tick-box (step 1).

Thank you — your form is complete

Your answers have been turned into a summary for Dr Gauci.

✍️ One more thing — because you mentioned trouble holding on, please also complete the short bowel-control questionnaires (about 8 minutes)

Note text preview (staff use)

Dr Chahaya Gauci MBBS MS FRACS · Suite 4, 29–33 Orlando Street, Coffs Harbour NSW 2450 · (02) 6651 6211
If you are unwell right now with severe pain, heavy bleeding or fever, call 000 or go to your nearest emergency department.