Urology Pre-Operative Assessment Form
Patient Information
Full Name
Date of Birth
Medical Record Number
Gender
Male
Female
Other
Contact Number
Medical History
Relevant Medical Conditions
Previous Surgeries
Allergies
Urological History
Diagnosis
Previous Urological Procedures
Current Urological Symptoms
Medication
Current Medications
Anticoagulants/Antiplatelets
Pre-Operative Assessment
Examination Findings
Pre-Operative Investigations
ASA Grade
I
II
III
IV
V
Planned Procedure Details
Procedure Name
Procedure Date
Surgeon
Anaesthetist
Notes / Additional Comments