Pre-Operative Assessment Form

Pre-Operative Assessment Form — Form Fields

This healthcare template includes 6 fields. Complete a pre-operative health assessment for patients scheduled for a surgical procedure. Captures medical history, current medications, anesthesia concerns, and NPO status. Ensures the surgical team has complete information before the procedure. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Scheduled Procedure (text, required)
• Known medical conditions (checkboxes, optional) — options: Diabetes, Heart disease, Hypertension, Asthma / COPD, Kidney disease, Blood clotting disorder, None
• Have you had a previous adverse reaction to anesthesia? (multiple choice, required) — options: No, Yes – please describe below, Unknown
• NPO (nothing by mouth) status (multiple choice, required) — options: NPO since midnight, Clear liquids only after midnight, I ate or drank this morning
• Current Medications and Allergies (long text, required)