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Pre-Surgical Screening Form - Free Healthcare Template | ZenBuild | ZenBuild

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Pre-Surgical Screening Form

Screens patients for health factors and risk indicators prior to a surgical procedure.

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Pre-Surgical Screening Form

Screens patients for health factors and risk indicators prior to a surgical procedure.

Patient Full Name*

Date of Birth*

Scheduled Procedure*

Surgery Date*

Current medical conditions

DiabetesHeart diseaseHigh blood pressureAsthma / COPDBlood clotting disordersSleep apnea

List all current medications including blood thinners*

Have you had problems with anesthesia previously?*

YesNo

Do you smoke or use tobacco products?*

YesNoFormer smoker

Patient Signature*

By signing, you agree this constitutes an electronic signature.

Template Details

CategoryHealthcare

IndustryHealthcare

Fields9

Uses0

Views1

healthcaresurgerypre-opscreeninganesthesia