Oncology Surgery Pre-Operative Assessment Form
Patient Information
Full Name
Date of Birth
Medical Record Number
Contact Number
Referring Physician
Surgical Details
Planned Surgery
Date of Surgery
Diagnosis
Surgeon
Medical History
Comorbidities
Previous Surgeries
Allergies
Medications
Pre-Operative Assessment
Height (cm)
Weight (kg)
BMI
Vital Signs
ASA Status
I
II
III
IV
V
Relevant Investigations/Results
Other Clinical Notes
Consent & Plan
Consent Obtained From
Special Considerations
Planned Post-Op Care