PRE-OPERATIVE MEDICAL ASSESSMENT (ADULT)
PRE-OPERATIVE MEDICAL
ASSESSMENT (ADULT)
Planned Surgical Procedure: ___________________________________________________________________________________
Date Planned Surgery: ________________ Hospital/Location of Surgery: _______________________________________________
Attending Surgeon: ___________________________________________________________________________________________
History of Present Illness:
? All relevant preoperative PMH listed below was reviewed and found to be negative unless specified below.
Past Medical History
Yes
Date
Cardiac History
CKD Stage _____ /Dialysis
Pulmonary Hypertension (latest PAP ___)
TIA/CVA/hemiplegia/hemparesis/residual deficit ______
Congenital heart disease
Yes
Date
? ETOH/Drinks
per week:
? Smoking status,
# pack years:
? Counseling
provided?
MI ( yes, no, 4 ? ................
................
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