Pre-Operative Assessment Form
Patient Information
Name
Date of Birth
Gender
Medical Record Number
Assessment Date
Procedure Information
Planned Procedure
Surgeon
Anesthetist
Medical History
Relevant Medical History
Current Medications
Allergies
Examination
Vital Signs
Systemic Examination
Investigations
Investigations / Results
Assessment & Plan
Assessment
Plan / Recommendations
Pre-Operative Clearance
Clearance Granted
Clearance Not Granted
Assessor Name
Signature
Date