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Pre-Operative Health Screening Form - Free Healthcare Template | ZenBuild | ZenBuild

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Pre-Operative Health Screening Form

Screen patients prior to elective surgery for anesthesia risks, chronic conditions, and current medications. Helps the surgical team prepare for safe procedural care.

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Pre-Operative Health Screening Form

Please complete this form at least 48 hours before your scheduled procedure. Accurate responses are essential for your safety.

Patient Name*

Scheduled Procedure and Date*

Current Medical Conditions (select all that apply)

Heart disease or arrhythmiaHigh blood pressureDiabetesAsthma or COPDKidney or liver diseaseBlood clotting disorderNone of the above

Current Medications and Dosages*

Have you ever had a reaction to anesthesia?*

YesNoUnsure

Do you smoke or use tobacco?*

NoYes — current smokerFormer smoker

Have you had anything to eat or drink in the past 8 hours?*

No — fasting as instructedYes — water onlyYes — food or other beverages

Additional Medical Information

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

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healthcarepre-opsurgeryanesthesiasurgical clearance