Neurosurgery Preoperative Assessment Form
Patient Information
Full Name
Date of Birth
MRN/ID Number
Age
Sex
Male
Female
Other
Contact Number
Address
Surgical Information
Diagnosis
Planned Procedure
Surgeon
Anesthetist
Date of Surgery
Medical History
Comorbidities
Current Medications
Drug Allergies
Previous Surgeries
Smoking History
Alcohol Use
Physical Examination
Weight (kg)
Height (cm)
Blood Pressure (mmHg)
Heart Rate (bpm)
Neurological Examination
Other Findings
Investigations
Bloods / Labs
Imaging
Other Investigations
Anaesthetic Assessment
ASA Grade
I
II
III
IV
V
Airway Assessment
Anaesthetist Comments
Consent
Consent Discussions
Patient/Guardian Signature
Date