PRE-OPERATIVE MEDICAL ASSESSMENT (ADULT) - Mount Sinai Health System
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
CKD Stage _____ /Dialysis TIA/CVA/hemiplegia/hemparesis/residual deficit ______ DVT/PE Anemia Active infection/sepsis Asthma/COPD Chronic Resp Failure on Home O2 Cancer Chronic Steroids Cirrhosis Coagulopathy/on anticoagulation
Diabetes ( Insulin Yes / No )
HIV/AIDS
Chronic Hepatitis B/C /treated Obesity w/hypoventilation syndrome OSA (if yes, is the patient adherent to CPAP?) STOPBANG
Other:
Date
Cardiac History
Yes
Pulmonary Hypertension (latest PAP ___)
Congenital heart disease
MI ( yes, no, 4
? ................
................
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