Patient Information
Full Name
Date of Birth
Medical Record Number
Sex
Male
Female
Other
Medical History
Cardiac Diagnosis
Comorbidities
Previous Surgeries
Allergies
Current Medications
Pre-Operative Assessment
Vital Signs
Physical Examination
ECG Findings
Chest X-Ray Findings
Laboratory Results
Risk Factors
Smoking Status
Current Smoker
Former Smoker
Never Smoked
Diabetes
Yes
No
Hypertension
Yes
No
Other Risk Factors
Planned Surgery
Type of Surgery
Date of Surgery
Surgeon
Pre-Operative Instructions & Notes
Pre-Op Orders
Additional Notes