Orthopedic Surgery Pre-Operative Assessment Form
Patient Information
Patient Name
Date of Birth
Medical Record Number
Sex
Male
Female
Other
Surgical Details
Planned Surgery Date
Planned Procedure
Surgeon
Side
Right
Left
Bilateral
Medical History
Allergies
Past Medical History
Past Surgical History
Current Medications
Anticoagulant/Antiplatelet Use
Anesthesia Assessment
ASA Classification
I
II
III
IV
V
Airway Assessment
NPO Status
Preoperative Labs & Imaging
Labs (Hemoglobin, INR, etc.)
Imaging
Risk Assessment
Special Risk Factors (DVT, Infection, Cardiac, etc.)
Consent
Consent Obtained
Yes
No
Consent Date