CHECK YES, NO OR N/A FOR ITEMS 1 TO 4 AND CHECK YES, NO OR N/A FOR ITEMS 1 TO 20 AND RECORD INITIALS RECORD INITIALS YES NO N/A INITIALS YES NO N/A INITIALS 1. ID bands applied 2. 2 Blood bands applied #_____________ 1. Wearing ID Band that Autologous/donor directed blood avail are legible 3. Blood consent signed and witnessed and 2. Blood bank two ID on chart Bands in place 4. If no blood consent, blood refusal form 3. Consent Signed and signed and on chart Witnessed 5. Consent signed and witnessed and on 4. Laterality on the chart Consent form is 6. Laterality identified on the consent form. consistent with: Surgery will be on the (circle one) - the OR schedule Right Left Bilateral Midline - patient response - the pre-op checklist 7. Laterality on the consent form is consistent with the patient's response 5. Allergies 8. Allergies No known allergies ____________________________________________ Latex ____________________________________________ 9. Last Food and Drink since___________ 6. Time Arrived in Pre-op Holding_________________ 10.Thromboprophylaxis 7. Chart Checked for Completeness_______________ Risk Status Low Med High 8. IV Fluids Amount _____________________ 11. Pre-op medication Time:___________________________ Signature_____________ Initials_________________ Medication_______________________ 12. Vital Signs NOTE_______________________________________ BP______________ P_____________ ____________________________________________ Temp ___________ RR____________ ____________________________________________ 13. Voided Time___________________ 14. Height__________ Weight__________ STATEMENT OF PATIENT COMPLIANCE 15. Patient personal belongings: I AM AWARE OF THE DANGER TO ME OF FOOD OR Dentures_________________________ LIQUID (INCLUDING WATER, COFFEE, OR TEA) IN Corrective lenses __________________ MY STOMACH DURING ANESTHESIA AND I Hearing aid ______________________ Jewelry _________________________ CERTIFY THAT I HAVE HAD NOTHING TO EAT OR Clothing or other___________________ DRINK SINCE_______________________________ Disposition EXCEPTIONS: ______________________________ □ Admission Services I CERTIFY THAT I HAVE AN ESCORT HOME □ Family Member (____________) WHOSE NAME IS: ___________________________ □ Remains w/Patient PATIENT: __________________________________ □ Other_____________________ WITNESS: __________________ DATE: _________ 16. Nail Polish Removed 17. Isolation *See Isolation Guidelines on Isolation Precautions Guidelines May go to Pre-op May go to PACU opposite side. Type________________ Airborne No No 18. Most recent investigations/results: Respiratory (Droplet) No No X-rays, Scans, Bloods, BM etc. Strict No No 19. Medical record with chart Contact No Yes (in isolation room) Special Handling Yes Yes 20. Addressograph plate on chart Protective (CJD) No No