Pre-Operative Health Screening Form

Pre-Operative Health Screening Form — Form Fields

This healthcare template includes 8 fields. Screen patients prior to elective surgery for anesthesia risks, chronic conditions, and current medications. Helps the surgical team prepare for safe procedural care. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Scheduled Procedure and Date (text, required)
• Current Medical Conditions (select all that apply) (checkboxes, optional) — options: Heart disease or arrhythmia, High blood pressure, Diabetes, Asthma or COPD, Kidney or liver disease, Blood clotting disorder, None of the above
• Current Medications and Dosages (long text, required)
• Have you ever had a reaction to anesthesia? (multiple choice, required) — options: Yes, No, Unsure
• Do you smoke or use tobacco? (multiple choice, required) — options: No, Yes — current smoker, Former smoker
• Have you had anything to eat or drink in the past 8 hours? (multiple choice, required) — options: No — fasting as instructed, Yes — water only, Yes — food or other beverages
• Additional Medical Information (long text, optional)