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Pre Procedure Evaluation

Please fill both forms out and submit each one.

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Age

Height

Weight

BMI

Diagnosis

Procedure

Anticipated to be prolonged and/or complex

SpO2

BP

HR

RR

Temperature

Medications:

Allergies

Surgical History

Previous problem with anesthesia or sedation (PONV, etc)

Labs

Labs:

None Indicated
HCG
Neg
Pos

Anesthetic Plan

I have explained the anesthetic plan, options, and pertinent complications including when appropriate: death, severe neurological Impaiment and blindness. The patient and /or legal guardian has communicated to me an understanding of both the anesthetic plan and inherent risks. Patient history reviewed by anesthesia provider.

Airway

Please fill out both sides of the form and submit each one.

MP

1
2
3

Teeth

Multiple Missing
Dent Upper
Dent Lower

Neck ROM

Normal
Limited

Checkboxes

History of Difficult airway
Hx of Stridor
Hx of Tracheal Stenosis

Checkboxes

Macroglossia
Tonsillar hypertrophy
No visible uvula

Checkboxes

Previous Neck Raditation
Unstable cervical Spine
Tracheal deviation

Checkboxes

Micrognathaia
Retroganathaia
Limited Mouth Opening

CARDIAC

HTN
Abnormal EKG
Pacemaker
Hyperlipidemia
RRR
Murmurs

Cath

Stress Test

EKG

Echo

PULMONARY

Sleep Apnea
on CPAP
COPD
Asthma
Clear Bilateral
Equal Bilateral

GASTROINTESTINAL

GERD
Gastroparesis
Swallow dysfunction

HEPATIC

Hepatitis A B C
Recreational drug use
Ascites

NEURO

Seizures
Migraines
CN IX or X Impairment
CVA/TIA
Neuropathy
Chronic Pain Syndrome
Degenerative Neurological Disease (MS, MG, Parkinsons, ALS, etc)

RENAL

Renel Failure

Endocrine

DM
Thyroid Disease

HEME/ONCOLOGY

Anemia
Sickle-Cell
Bleeding Disorder
DVT

MUSCULOSKELETAL

Obese
Advanced RA
Dysmorphic Facial Features
Hypotoria
Fibromyalgia

PSYCHOSOCIAL

Bipolar
Anxiety
Depression
Combative or Uncooperative

Pre-op Instructions

Click The Book Icon above to view the Pre-Op Instructions

PDF FORMAT

Click the Icon above to download the Form in PDF format.

Free Estimation

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Contact Me

Holley Anesthesia

Contact Info

lhsleep6@gmail.com

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