Patient Profile
Date of Birth (D.O.B.)_________  BP_________   Age_______
Pulse___________   Height____________   Weight__________
Respiratory___________    Temp_________
Date of Surgery (D.O.S.)________________

Diagnosis: (ICD code)

Procedure: (CPT code)

Indication: pain, deformity, pressure, ulcer, tumor, wound, infection, elective surgery?

Past History:

  • Cardiovascular
  • pulmonary
  • GI
  • Neuro
  • Heme
  • Endocrine
  • Previous Surgery
  • Allergies
  • Medications (currently taking)

Physical Exam:

ASA Classification: I- normal, II-systemic disease, III-severe(DM, HTN, obese, MI), IV-life threatening (stent, ESRD), V-not surviv without surgery, VI-declared brain dead

Anesthesia: under local, MAC, general, spinal

Lab Tests: blood, EKG, CBC, BMP

Hemostasis: Tourniquet @ ankle or thigh level

Position: Supine, Prone, Lateral

Resident:______________________________  Signature:_______________________________

Doctor:_______________________________ Date:_________________ Time:_____________________


– Transportation: [________]
– Preadmit [________] or Same day surgery [________] or Hoptel [________]
– CBC CMP PT/INR within 1 month: Done on [________] or Ordered [________]
– Type and Screen/Cross: Ordered [________]</span
– EKG within 4 months: Done on [________] or Ordered [________]
– CXR within 6 months: Done on [________] or Ordered [________]
– Antiplatelet/anticoagulation plan: [________]
– Medication Reconciliation done?