PROFORMA

Patient details (use addressograph sticker) Assessment date:

Name: ...................................................................... Reassessment date:

Address: ................................................................... (Use a different colour pen)
Unit number: ....................... DoB: ..........................

Consultant: PvH PM GT NP SR PC AT JT ST DP

Diagnosis:

Proposed Operation:

Current Symptoms:

Past Medical History: (If as per nursing assessment tick here )

Add any additional comments...

Drug & Allergy History: (If as per nursing assessment tick here )
Add any additional comments...

Is the patient taking aspirin/warfarin/clopidogrel? Yes No

If yes, give details and action required ...........................................................................

Social History: (If as per nursing assessment tick here )

Add any additional comments...

Occupation:

Hand Dominance:

Neurosurgery Pre-Assessment Proforma. I Anderson, H Chance & S Thomson. December 2009

Overall Appearence:

Cardiovascular System:

Respiratory System:

Gastrointestinal System:

Neurological Examination:

Cranial Nerves:
Right Lef

I Olfactory
II Fundi
Visual acuity

Visual fields

III IV VI Pupil size

Direct
Consensual
Accommodation
Eye movements

V Motor
Sensory
Corneal reflex
ALWAYS TEST CORNEAL REFLEXES IN ‘TRIGEMINAL’ PATIENTS

VII Motor
VIII Hearing

IX X Gag reflex
XI Shoulder shrug
XII Tongue

Neck movements:

Neurosurgery Pre-Assessment Proforma. I Anderson, H Chance & S Thomson. December 2009

Upper Limbs:
Right Lef

Inspection
Tone
Power Shoulder abduction
Shoulder adduction
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
Finger absuction
Finger adduction
Reflexes Triceps
Biceps
Supinator
Co-Ordination
Hoffman’s

Lower Limbs:
Right Lef

Inspection
Tone
Power Hip flexion
Hip extension
Knee flexion
Knee extension
Ankle dorsiflexion
Ankle plantarflexion
EHL
FHL
Reflexes Knee
Ankle
Plantars
Co-Ordination
Straight Leg Raise

Gait:

Sensation: Fully intact 

Some abnormal findings (document overleaf) 

Neurosurgery Pre-Assessment Proforma. I Anderson, H Chance & S Thomson. December 2009

Neurosurgery Pre-Assessment Proforma. I Anderson, H Chance & S Thomson. December 2009
 Investigations: (please tick)

Pituitary Function bloods

FBC  Chest X-ray TFTs (inc T3)
U&E  ECG (everyone over Prolactin
50)
LFTs ECHO IGF-1
Bone Profile Spirometry LH
Clotting screen  Pulmonary fuction FSH
Group & save  C-Spine X-rays Testosterone
Sickle cell T-Spine X-rays ACTH
Glucose L-Spine X-rays Cortisol
Others (please state) Serum HBG

Anaesthetic Review:
Is not required 
Is required (state reason/question to be answered below) 

Results:

Hb Na T3
WCC K T4
Plts Creat TSH
INR Urea Prolactin
PT Glucose IGF-1
APTT Cortisol LH
Serum HBG FSH
Testost
ACTH

ECG

CXR

MRSA Screening Result

MRSA Prophylaxis Chart Completed? Yes  Not Required 

Final Checklist:

 Drug chart? Yes 

 MRSA prophylaxis (if appropriate)? Yes  N/A 
 ‘Results’ section completed? Yes 
 Patient fit for surgery? Yes  No 

Pre-assessment performed by: Date:

Results checked by: Date:
Re-assessment performed by: Date:

Neurosurgery Pre-Assessment Proforma. I Anderson, H Chance & S Thomson. December 2009

Repeat results checked by: Date:

Neurosurgery Pre-Assessment Proforma. I Anderson, H Chance & S Thomson. December 2009