Preoperative Nursing Assessment Form
Patient Identification
Patient Name
Hospital Number
Date of Birth
Age
Gender
Male
Female
Other
Date of Assessment
Surgical Information
Planned Surgery
Surgeon
Anesthesiologist
Operating Room
Medical History
Medical Conditions
Allergies
Medications
Previous Surgeries
Physical Assessment
Height (cm)
Weight (kg)
Vital Signs
Airway Assessment
Cardiovascular Assessment
Respiratory Assessment
Other Physical Findings
Nursing Assessment
Psychological Status
Skin Condition
Mobility Status
Other Notes
Consent Verification
Consent Signed
Yes
No
Consent Details
Assessment Completed By
Name
Signature
Date