Obstetric Pre-Operative Assessment Form
Patient Details
Name
Hospital Number
Date of Birth
Age
Consultant
Date of Assessment
Obstetric History
Gravidity
Parity
Gestational Age
Expected Date of Delivery
Previous Obstetric Problems
Medical & Surgical History
Significant Medical Conditions
Previous Surgeries
Medications
Allergies
Pre-Operative Assessment
Indication for Surgery
Planned Procedure
Findings on Examination
Investigations (Lab/Imaging)
Anaesthetic Assessment
Airway Assessment
ASA Classification
I
II
III
IV
V
Anaesthetist Comments
Consent & Preparation
Consent Obtained
Yes
No
Blood Group
Cross-match Required
Yes
No
Preparation Instructions
Additional Notes
Comments