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Pre-Operative Care Record
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Surgeon
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NPO Since:
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Allergies
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Latex Allergy?
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Diagnosis
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Procedure
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Medical History
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Asthma
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Diabetes
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Hypertension
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Smoker
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History of Substance Abuse
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Do you take Herbal Supplements (i.e. St. Johns Wart)
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Past Surgical History
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History of malignant Hyperthemia? (or Family History)
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Medications
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Other:
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Aldrete Score PRE-OP
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Moves Extremities
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Resiprations
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BP
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Alert and Oriented
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Oxygen
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Total:
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Urine Pregnancy Test
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Procedure Completed By:
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Vitals (auto-completed)
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IV Site
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GA
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Skin Assessment
• • •
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Consents Signed
• • •
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Forms Completed
• • •
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Nurse Signature
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Nurse Signed - Date/time
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Narc Count
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Pre-Op - Medication Name
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Quantity
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Counted By:
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Witness:
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Departure - Medication Name
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Quantity
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Counted By:
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Witness:
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