Ambulatory (Day Surgery) Pre-Operative Assessment Form
Patient Name
Date of Birth
Sex
Male
Female
Other
MRN / Hospital No.
Surgery / Procedure
Date of Surgery
Medical History / Comorbidities
Allergies
Medications (including anticoagulants, antiplatelets, etc.)
Anesthesia History (any previous problems, difficult intubation, malignant hyperthermia, etc.)
Family History (anesthesia issues, bleeding disorders, etc.)
Social History (Smoking, Alcohol, Recreational Drugs)
Fasting Status (Date/Time of last food & drink)
Examination
Height (cm)
Weight (kg)
Vital Signs
Airway Assessment
Other Relevant Findings
Investigations (if any)
ASA Physical Status Classification
I
II
III
IV
V
Assessment / Plan
Assessed By
Date
Signature