Neurosurgery Pre-Operative Assessment Form
Patient Information
Full Name
Date of Birth
Sex
Male
Female
Other
MRN / Hospital ID
Contact Number
Clinical Details
Diagnosis
Proposed Surgery
Indication for Surgery
Past Medical History
Past Surgical History
Medications
Allergies
Physical Examination
General Examination
Neurological Examination
Laboratory & Imaging Results
Blood Tests
Imaging (CT/MRI etc.)
Other Results
Anaesthesia Assessment
Pre-Operative Instructions
Consent
Date
Clinician Name
Signature