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PRE-OP DIAGNOSIS
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PROCEDURE
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Nurse Signature
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MEDICAL HISTORY
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EGGS/SOY/LATEX ALLERGY
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TABACCO
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ETOH
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DRUG USE
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CURRENT MEDICATIONS
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Refer to Medication Reconciliation List
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Aspirin consumption
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Interferences placing pt at risk for falsely elevated blood sugar level (GDH-PQQ)
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NEURO
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NEURO
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CARDIOVASCULAR
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CARDIOVASCULAR
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RESPIRATORY
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RESPIRATORY
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Hx of Sleep Apnea
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PACU has CPAP machine available
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RENAL
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RENAL
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HEPATIC
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HEPATIC
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DIABETES (Blood Sugar Reference 70-110)
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DIABETES (Blood Sugar Reference 70-110)
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MUSCULO-SKELETAL
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MUSCULO-SKELETAL
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BLOOD CLOTS / BLEEDING DISORDERS
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BLOOD CLOTS / BLEEDING DISORDERS
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CANCERS
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CANCERS
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IMMUNIZATION HX (As Clinically Relevant)
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IMMUNIZATION HX (As Clinically Relevant)
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HX OF MALIGNANT HYPERTHERMIA
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HX OF MALIGNANT HYPERTHERMIA
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PREVIOUS ANESTHETICS (Indicate any complications)
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PREVIOUS ANESTHETICS (Indicate any complications)
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The portion below is to be completed by the Anesthesia Provider
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Physical Exam
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Mallampatti Score
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ASA Classification
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HEART
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Others, please specify
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LUNGS
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Others, please specify
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ABD
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Others, please specify
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TEETH
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Others, please specify
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SKIN
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Others, please specify
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PSYCH
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Others, please specify
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NUTRI
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Others, please specify
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Plan of Anesthesia Explained to Patient
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Plan of Anesthesia
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Labs Reviewed
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Patient Gave Consent
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Discussed risks, alternatives and possible complications of anesthesia with patient
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Anesthesia providers signature
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POST OPERATIVE EVALUATION
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Satisfactory
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Complications
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Complications
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Comments / Follow-up
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Other Notes
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The patient has fully recovered from the effects of anesthesia.
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Anesthesia providers signature
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