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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