Pediatric Pre-Operative Assessment Form
Patient Information
Name
Date of Birth
Age
Medical Record Number
Gender
Male
Female
Other
Parent / Guardian Information
Parent/Guardian Name
Contact Number
Relationship to Patient
Surgical Procedure
Planned Procedure
Date of Surgery
Surgeon Name
Medical History
Relevant Medical History
Previous Surgery
Allergies
Current Medication
Physical Examination
Weight (kg)
Height (cm)
Temperature (°C)
Pulse (bpm)
Respiratory Rate
Blood Pressure
Other Exam Notes
ASA Status
ASA Classification
I
II
III
IV
V
Anesthesia Assessment
Fasting Status
Airway Assessment
Anesthesia Notes / Plan
Assessor Name
Date of Assessment