Ambulatory Surgery Pre-Operative Assessment Form
Patient Information
Patient Name
Date of Birth
Medical Record Number
Allergies
Surgical Information
Planned Procedure
Date of Surgery
Surgeon
Medical History
Relevant Medical History
Current Medications
Assessment & Examination
ASA Classification
I
II
III
IV
Vital Signs
Physical Exam Notes
Anesthesia Assessment
Airway Evaluation
Anesthesia Plan
Consent & Preparation
Surgical Consent Verified
Yes
No
NPO Status
Clinician
Clinician Name
Date