PLACE LABEL HERE

ANESTHESIA PRE-OP HISTORY, ASSESSMENT

AND POST ANESTHESIA EVALUATION

DATE: AGE: PROPOSED PROCEDURE:

Diagnosis:
Medical History: C.N.S.: Hct: Hgb:
Cardiovascular: WBC: PLTs:
METS:
Respiratory: Tobacco: Cr:
BUN:
Hepatic: EtOH:
GLU:
Renal: Illicit Drugs: PT/PTT:
GI: CXR:
Musculoskeletal: LMP: EKG:
Endocrine: NPO: ABGs:
Hematologic: hCG:  Pos.  Neg.  N/A
Previous Surgeries: Anesthesia Complications:
 Yes  No
 Patient  Family
__________________________
Allergies: Clearance on chart:

Medicines:

Physical: Ht: ______ Wt.: ______ kg BMI: ______ BP: _____ / _____ T: ______ P: _______ R: _______ O2 Sat: ________

NP Assessment Airway Lungs Heart

Other
Preliminary Plan: ___________
Pre-op Medication:

LIP Signature: _____________________________ Time: _______ RN Signature: ___________________________ Time: _______

Pre-Anesthesia Evaluation Day of Surgery ASA Class 1 2 3 4 5 E Anesthesia Plan:

Airway Lungs Heart

 Medical History Reviewed by Anesthesia Provider Other

Pre-op Medication:
Post procedure care expected to include ICU 
Patient has been informed of the risks, benefits, potential complications and alternatives of anesthesia and has had the opportunity to
ask questions.
Date:_______________ Time: ___________Signature:__________________________________ Physician Number_____________
Post Anesthesia Evaluation:
Patient meets discharge criteria based on review of vital signs, cardiopulmonary status, mental status, pain, nausea & vomiting well
controlled, postoperative hydration adequate
 Patient does not meet discharge criteria based on post anesthesia complications: ________________________________________
Plan: _____________________________________________________________

Date:_______________ Time: ___________Signature:__________________________________ Physician Number_____________

*1-1070* FORM 1-1070 REV. 09/2011 WHITE: Medical Record CANARY & PINK: Anesthesia Page 1 of
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 Send copy to pharmacy_________ (initials)
FORM #3-20 REV. 08/2005 Page 2 of 2