Urological Surgery Pre-Op Patient History
Patient Information
Full Name
Date of Birth
MRN/ID
Sex
Male
Female
Other
Surgical Details
Planned Procedure
Surgery Date
Surgeon
Medical History
Relevant Medical History
Current Medications
Allergies
Urological History
Urological Diagnosis/Issues
Previous Urological Surgery
Anesthesia History
Problems with Anesthesia
Additional Notes
Other Relevant Information