Preoperative Physical Examination Checklist
Patient Name:
Date of Birth:
Medical Record #:
Vital Signs
Blood Pressure:
Heart Rate:
Respiratory Rate:
Temperature:
O₂ Saturation:
Physical Examination
General Appearance:
Airway/Neck:
Lungs:
Heart:
Abdomen:
Extremities:
Neurologic:
Labs & Tests Reviewed
CBC
CMP
Coagulation
ECG/EKG
Chest X-ray
Additional Notes
Examiner Name:
Date:
Signature: