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Patient Preoperative History Form
Patient Preoperative History Form
scpimaCrossing
2014-12-08T01:22:44+00:00
Patient Preoperative History Form
Patient Name
*
DATE OF PROCEDURE
*
PROCEDURE TIME
DATE CALLED
PRE-OP CALL RN
SPOKE WITH
PT. SPANISH SPEAKING ONLY OTHER:
CHECK-IN TIME:
PRE-OP ADMISSION TIME:
NKA ALLERGIES:
NAME PT LIKES TO GO BY
Ebola Screening Complete:
Yes
Follow up Needed:
Yes
No
PREVIOUS SURGERY
YEAR
PREVIOUS SURGERY
YEAR
PREVIOUS SURGERY
YEAR
ANESTHESIA REACTION BY SELF? (Malignant Hyperthermia)
No
Yes
Other
ANESTHESIA REACTION BY BLOOD RELATIVE? (Malignant Hyperthermia)
No
Yes
Other
(CHECK IF ANY PAST OR PRESENT CONDITIONS)
CARDIOVASCULAR
CHEST PAIN
HEART ATTACK
IRREGULAR HEARTBEAT
BLOOD PRESSURE
MITRAL VALVE PROLAPSE
PACEMAKER (REQUIRED DOCUMENTATION PRESENT)
BLEEDING ABNORMALITIES
OTHER (PLEASE USE THE TEXTBOX PROVIDED)
GASTROINTESTINAL
ULCER
HIATAL HERNIA
GERD
LIVER DISEASE/HEPATITS
OTHER
MUSCULOSKELETAL
ARTHRITIS
LIMITED MOBILITY
MUSCLE DISEASE / WEAKNESS
BACK / NECK TROUBLE
USE OF AID
METAL IMPLANTS
OTHER
RESPIRATORY
TOBACCO USE:
EMPHYSEMA / COPD
ASTHMA
RECENT DYSPNEA / SOB / COUGH
OXYGEN USE
SLEEP APNEA
C-PAP MACHINE
TUBERCULOSIS / RECENT EXPOSURE
OTHER
GENITO - URINARY
KIDNEY PROBLEMS
BLADDER PROBLEMS
PROSTATE PROBLEMS
LAST MENSTRUAL PERIOD DATE
POSSIBILITY OF PREGNANCY?
YES
NO
N/A
OTHER
ENDOCRINE
DIABETES
THYROID
ADRENAL
OTHER
NEUROLOGICAL
STROKE / TIA YEAR :
NUMBNESS
SEIZURES
HEADACHES
OTHER
SOCIAL
ALCOHOL USE
DRUG USE
INFECTIOUS DISEASE
PAIN (0 = NONE 10 = WORST)
LOCATION
OTHER MEDICAL PROBLEMS
ALERT
ORIENTED
DROWSY
DISORIENTED
CALM
ANXIOUS
OTHER
GAIT
STEADY
UNSTEADY
ASSISTIVE DEVICE
HT.
WT. (STATED)
ACTUAL
LBS. / KGS.
BMI
RECENT WT. LOSS / GAIN (LBS.)
NPO FOOD
NPO DRINK
VITAL SIGNS:
SAO2%
BP
P
R
T
HEARTBEAT: REGULAR / IRREGULAR
BREATH SOUNDS: CTA OTHER
IV SOLUTION
SITE
CATHETER SIZE
TIME STARTED
NUMBER OF ATTEMPTS
STARTED BY
COMMENTS
INITIALS
PRE-OP NURSE SIGNATURE
DATE
TIME
ADDITIONAL INFORMATION
HARD OF HEARING
HEARING-AID(S): L / R OUT
VISUALLY IMPAIRED:
GLAUCOMA / CATARACTS
OTHER
COMMUNICATION BARRIER:
JEWELRY
OFF / WAIVER SIGNED
GLASSES
OFF
CONTACTS
OUT
LENS IMPLANTS
L
R
DENTURES: UPPER
OUT
LOWER
OUT
RETAINER
OUT
BRACES
UPPER
LOWER
LOOSE
CHIPPED
CAPPED TEETH
HAS OWN CRUTCHES / BOOT
1. PRE-PROCEDURE MEDICATION
ROUTE
SITE
INITIALS
RESPONSE
PRE-PROCEDURE TESTS:
HGB
( < 8.0 = CRITICAL VALUE - REPORTED TOMD)
RN INITIALS
GLUCOSE
( < 70 or > 200 = CRITICAL VALUE – REPORTED TO MD)
TIME
Verification
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