ENT Surgery Pre-Op Clinical Evaluation Form
Patient Information
Full Name
MRN / Hospital ID
Date of Birth
Gender
Male
Female
Other
Contact & History
Contact Number
Referring Physician
Indication for Surgery
Medical History
Past Medical History
Past Surgical History
Drug Allergies
Medications
ENT Examination
General Examination
ENT Specific Findings
Airway Assessment
Mallampati Score
I
II
III
IV
Other Airway Concerns
Lab Investigations
Lab Results Summary
Assessment & Plan
Risk Assessment (ASA / Others)
Plan / Preparedness
Clinician Details
Name
Date
Signature