Pre-Surgical Screening Form

Pre-Surgical Screening Form — Form Fields

This healthcare template includes 9 fields. Screens patients for health factors and risk indicators prior to a surgical procedure. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Scheduled Procedure (text, required)
• Surgery Date (text, required)
• Current medical conditions (checkboxes, optional) — options: Diabetes, Heart disease, High blood pressure, Asthma / COPD, Blood clotting disorders, Sleep apnea
• List all current medications including blood thinners (long text, required)
• Have you had problems with anesthesia previously? (multiple choice, required) — options: Yes, No
• Do you smoke or use tobacco products? (multiple choice, required) — options: Yes, No, Former smoker
• Patient Signature (signature, required)