Orthopedic Surgery Pre-Operative Screening Sheet
Patient Information
Patient Name
Date of Birth
Medical Record Number
Date
Surgical & Diagnosis Details
Scheduled Surgery
Diagnosis / Indication
Scheduled Date
Medical History
Allergies
Medications
Comorbidities / Previous Illnesses
Pre-Operative Screening
Bleeding Disorders
Yes
No
Cardiac Disease
Yes
No
Respiratory Disorders
Yes
No
Diabetes Mellitus
Yes
No
Renal Disease
Yes
No
Previous Surgeries
Other Relevant Conditions
Recent Laboratory & Imaging
Hemoglobin
WBC / Platelets
Blood Sugar
ECG
Chest X-Ray
Anesthesia Assessment
Consulted Anesthesiologist
ASA Grade
Consent
Consent Taken
Yes
No
Special Notes / Precautions