PRE - ANESTHETIC EVALUATION

PATIENT’S IDENTIFICATION
CURRENT MEDICATIONS
PROPOSED PROCEDURE

DIAGNOSIS
Age Height Weight Date temp pulse resp SpO2 BP

Time
kg ALLERGIES / NKDA

SURGICAL / ANESTHETIC HISTORY □ no personal or family history of anesthetic complications

LABORATORY STUDIES DIAGNOSTIC STUDIES

CBC CXR

WBC

Hgb Hct
TEETH □ Appear normal □ Decayed □ Missing □ Other
□ Dentures Full: Upper / Lower Partial: Upper / Lower
Platelets ECG
AIRWAY / HEAD & NECK □ No apparent airway problems
Electrolytes

RESPIRATORY □ WNL Na Cl BUN Glucose

□ Asthma K CO2 Crea
□ COPD tinine Other
□ Recent URI
□ Sleep Apnea Other
□ Smoker _______packs / day x _______yrs
CARDIOVASCULAR □ WNL
□ Angina □ Hypercholesterolemia / Hyperlipidemia
□ ASHD / CAD □ MI NPO after: time__________________date______________________
□ ASPVD □ Pacemaker
□ CHF □ Valvular Disease
□ Dysrhythmia ANESTHESIA PLAN
□ HTN
ASA 1 2 3 4 5 6 E
HEPATO / GASTROINTESTINAL □ WNL
□ Hiatal Hernia / Reflux Mallampati Classification : 1 2 3 4
□ Drug / Alcohol Abuse
□ Liver Disease Anesthesia Plan: GEN - REG - IV Sed - L/MAC
□ Nausea / Vomiting
□ Ulcers Anesthesia plan, risks, benefits and alternatives discussed with
patient. Questions were answered. □ Yes □ No
NEURO / MUSCULOSKELETAL □ WNL Patient appears to understand; anesthetic plan and risks are
□ Arthritis □ Neuropathy accepted. Patient wishes to proceed and is determined to be an
□ CVA / TIA’s □ Paralysis appropriate candidate for the planned anesthesia.
□ DJD □ Seizures □ Yes □ No
□ Headaches
□ Muscle Weakness Patient identity, procedure and site verified. □ Yes □ No
□ Neuromuscular Disease
___________________________________ ______________
provider signature date / time
RENAL / ENDOCRINE □ WNL POST-OP VISIT
□ Diabetes: NIDDM / IDDM □ Chart reviewed. □ Patient visit
□ Renal Failure / Dialysis □ No apparent anesthetic complications
□ Recent Steroids
□ Thyroid Disease _______________________________ ______________________
signature date / time
OTHER □ WNL
□ Coagulopathy _________________________________________________________
□ Obesity patent identification
□ Pregnancy
□ Psychiatric Hx
PRE - ANESTHETIC EVALUATION