Obstetric Surgery Pre-Operative Evaluation Form
Patient Name
Hospital Number
Date of Birth
Age
Date of Admission
Expected Date of Surgery
Diagnosis
Gravida
Parity
Gestational Age (weeks)
Indication for Surgery
Relevant Medical / Surgical History
Allergies
Blood Group
Hemoglobin (g/dL)
BLOOD Ready?
Yes
No
Vital Signs
Blood Pressure
Pulse Rate
Temperature
Other Relevant Examination Findings
Investigations Performed
Medications/Pre-operative Orders
Anesthetist Evaluation Findings
Consent Obtained
Yes
No
Form completed by
Date