ENT Pre-Operative Assessment Form
Patient Information
Full Name
Date of Birth
Hospital Number
Gender
Male
Female
Other
Diagnosis & Planned Procedure
Diagnosis
Planned Procedure
History
Brief Relevant History
Examination
Height (cm)
Weight (kg)
Blood Pressure
Pulse (bpm)
ENT Examination Findings
Medical History
Allergies
Current Medications
Previous Surgeries
Other Relevant Medical History
Investigations
Blood Tests
Imaging
ECG
Other
Anaesthetic Assessment
Anaesthetic Considerations / Findings
Additional Notes
Notes