LAST 1 MONTH (SEE SOP FOR Dyspnoea limiting exertion to <1 flight or CXR: moderate COPD DEFINITIONS) YES NO Dyspnoea at rest/rate > 30 at rest or CXR: fibrosis or consolidation 2.22 CEREBROVASCULAR DISEASE 2.23 CURRENT OR RECENT (LAST 5 YR) CANCER DIAGNOSIS NO Yes, without hemiplegia NO Solid tumour, metastatic disease (including lymph node) Yes, with hemiplegia Solid tumour, local only Lymphoma Leukaemia 2.24 DEMENTIA 2.25 DIABETES MELLITUS YES NO Not diabetic Type 1 Type 2 (on insulin) Type 2 (diet-controlled only) Type 2 (non-insulin glucose-lowering medication) 2.26 HBA1C (%) 2.27 LIVER DISEASE (CONVERSION CALCULATOR FROM NO Cirrhosis or Hep B/C without portal hypertension MMOL/MOL OR MMOL/L CAN BE ACCESSED THROUGH THE WEBTOOL) Cirrhosis or Hep B/C with portal hypertension 2.28 ASA SCORE (1-5) 2.30 SMOKING STATUS Never smoked Ex-smoker > 6 months Ex-smoker <6 months Current smoker Unknown 2.31 SMOKING CESSATION REFERRAL 2.32 DAILY ALCOHOL CONSUMPTION YES – intensive YES – one off NO NONE 0-2 units 3-4 units >5 units UNKNOWN UNKNOWN 2.33 DOCUMENTED ASSESSMENT OF PERIOPERATIVE RISK 2.34 PLANNED POST-OPERATIVE CARE NO QUALITATIVE QUANTITATIVE WARD LEVEL 1 LEVEL 2 LEVEL 3 BOTH QUALITATIVE & QUANTITATIVE 2.35 BOWEL PREP YES NO N/A 2.36 PRE-OP CARBOHYDRATE DRINK YES NO UNKNOWN CARDIOPULMONARY EXERCISE TEST
(SEE SOP FOR DEFINITIONS) Dyspnoea limiting exertion to <1 flight or CXR: moderate COPD Dyspnoea at rest/rate > 30 at rest or CXR: fibrosis or consolidation LAST 1 MONTH YES NO 2.22 CEREBROVASCULAR DISEASE NO Yes, without hemiplegia Yes, with hemiplegia 2.23 CURRENT OR RECENT (LAST 5 YR) CANCER DIAGNOSIS NO Solid tumour, metastatic disease (including lymph node) Solid tumour, local only Lymphoma Leukaemia 2.24 DEMENTIA YES NO 2.25 DIABETES MELLITUS Not diabetic Type 1 Type 2 (on insulin) Type 2 (diet-controlled only) Type 2 (non-insulin glucose-lowering medication) 2.26 HBA1C (%) (CONVERSION CALCULATOR FROM MMOL/MOL OR MMOL/L CAN BE ACCESSED THROUGH THE WEBTOOL) 2.27 LIVER DISEASE NO Cirrhosis or Hep B/C without portal hypertension Cirrhosis or Hep B/C with portal hypertension 2.28 ASA SCORE (1-5) 2.30 SMOKING STATUS Never smoked Ex-smoker > 6 months Ex-smoker <6 months Current smoker Unknown 2.31 SMOKING CESSATION REFERRAL YES – intensive YES – one off NO UNKNOWN 2.32 DAILY ALCOHOL CONSUMPTION NONE 0-2 units 3-4 units >5 units UNKNOWN 2.33 DOCUMENTED ASSESSMENT OF PERIOPERATIVE RISK NO QUALITATIVE QUANTITATIVE BOTH QUALITATIVE & QUANTITATIVE 2.34 PLANNED POST-OPERATIVE CARE WARD LEVEL 1 LEVEL 2 LEVEL 3 2.35 BOWEL PREP YES NO N/A 2.36 PRE-OP CARBOHYDRATE DRINK YES NO UNKNOWN CARDIOPULMONARY EXERCISE TEST
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