Outpatient Pre-Operative Assessment Form
Patient Details
Full Name
Date of Birth
MRN / Hospital No
Contact Number
Address
Procedure Details
Planned Procedure
Proposed Date
Surgeon
Medical History
Relevant Past Medical History
Medications & Allergies
Current Medications
Allergies
Assessments
Height (cm)
Weight (kg)
BMI
Other Vitals / Observations
Airway Assessment
Airway Notes
Investigations
Baseline Investigations Requested/Performed
Summary & Plan
Summary
Perioperative Plan
Clinician Details
Name
Designation
Date
Signature