Patient Information
Patient Name
Date of Birth
Age
Gender
Male
Female
Other
Hospital No./ID
Parent/Guardian Name
Contact Number
Surgical Details
Diagnosis
Procedure
Date of Surgery
Surgeon
Medical History
Current Medications
Allergies
Past Medical History
Past Surgical History
Family History (Anesthesia Complications, Bleeding Disorders, etc.)
Pre-Operative Assessment
Weight (kg)
Height (cm)
Vital Signs
Airway Assessment
Cardiorespiratory Assessment
Other Relevant Examination
Laboratory/Investigation Results
Laboratory Findings
Imaging
Anesthesia Plan
Planned Technique
Special Considerations
Pre-Operative Orders/Preparation
Orders/Preparation
Assessed By
Date