Geriatric Pre-Operative Assessment Form
Patient Information
Full Name
Date of Birth
Medical Record Number
Sex
Surgical Information
Planned Procedure
Date of Surgery
Surgeon
Medical History
Comorbidities
Previous Surgeries
Medications
Allergies
Functional Assessment
Mobility Status
ADL (Activities of Daily Living)
Cognitive Status
Physical Examination
Vital Signs
General Examination
Risk Assessment
ASA Score
Frailty Score/Index
Other Risk Scores
Other Notes