Dental Surgery Pre-Operative Assessment Form
Patient Information
Full Name
Date of Birth
Contact Number
Email
Address
Medical History
Current Medications
Allergies
Past Medical Conditions
Previous Surgeries
Bleeding Disorders
No
Yes
Heart Conditions
No
Yes
Diabetes
No
Yes
Other Important Medical Details
Dental Assessment
Reason for Surgery
Planned Procedure
Pain Level (1-10)
Relevant Dental History
Consent & Notes
Consent Obtained
Yes
No
Clinician's Notes
Date of Assessment
Clinician Name