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Templates→Healthcare→Pre-Operative Assessment Form

Pre-Operative Assessment Form

Complete a pre-operative health assessment for patients scheduled for a surgical procedure. Captures medical history, current medications, anesthesia concerns, and NPO status. Ensures the surgical team has complete information before the procedure.

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Pre-Operative Assessment Form

Complete this pre-operative health assessment before your scheduled surgery.

Patient Full Name*

Scheduled Procedure*

Known medical conditions

DiabetesHeart diseaseHypertensionAsthma / COPDKidney diseaseBlood clotting disorderNone

Have you had a previous adverse reaction to anesthesia?*

NoYes – please describe belowUnknown

NPO (nothing by mouth) status*

NPO since midnightClear liquids only after midnightI ate or drank this morning

Current Medications and Allergies*

Template Details

CategoryHealthcare

IndustryHealthcare

Fields6

Uses0

Views1

healthcarepre-operativesurgeryassessmentpatient

Pre-Operative Assessment Form - Free Healthcare Template | ZenBuild | ZenBuild