Preoperative Assessment Checklist
Patient Details
Name:
Date of Birth:
MRN:
Surgery Date:
Surgeon:
Preoperative Checklist
Allergies checked
Medical history reviewed
Current medications documented
Recent lab results reviewed
Vital signs documented
Consent form signed
NPO status confirmed
Imaging reviewed (if applicable)
Other assessments complete
Airway Assessment
Mallampati:
Teeth Status:
Neck Mobility:
ASA Physical Status
Anesthesia Plan
Preoperative Instructions
Clinician Name & Date
Clinician:
Date: