Pre-Operative Checklist

* Indicates required field

Name *

First

Last

Surgery Date *

SOCIAL:

General Physical Condition: *

Issues with ability to self care / lift home *

Mobility and walking aids *

MEDICAL CONDITIONS:

Heart condition *

Heart Surgery/Stent in the last 12 Months *

Diabetes: *

Osteo or Rheumatoid Arthritis *

Asthma and your medications used for Asthma *

CPAP machine *

Smoking Status *

If Yes, Advised of increased infection risk 24/h after Surgery *

Alcohol Consumption *

If Yes, Advised of increased infection risk 24/h after Surgery *

Stroke *

Heartburn or reflux *

Implants or joint replacements *

Any previous problems with anaesthetics? *

Anxiety or insomnia: *

Other medical conditions HIV, Hep *

ANTICOAGULATION:

Bleeding disorder - platelets/Factor V *

Date ceased anti-coagulation *

Doctor notified re anti-coag? *

MEDICATIONS OF IMPORTANCE:

Ozempic / GLP-1 medication? If Yes, Date last taken *

CAG fasting for Ozempic form supplied *

Cholesterol meds + tendon rupture? *

Allergic to medication? *

If Yes, Allergies / alerts list: *

FINAL QUESTIONS FOR DR COLL:

Questions from patient to be discussed? *

Submit