Preoperative anesthesia checklist

Name of patient : Date:

Age(Years) : Sex : Weight (Kg): Height (Meters):
BMI:
Card number: Ward: Surgical Diagnosis:

Planned Procedure: Presentation:

Past surgical Yes No If yes, document illness:

illness
Past medical Yes No If yes, document illness:
illness

Current medical Yes No If yes, document illness:

illness

Current Yes No If yes, document medications:

medications

Known Yes No If yes, document allergy:

allergy

Smoking Yes No If yes, document number of pack year

Alcohol Yes No If yes, specify how much Other substance

Previous History of air Ye No If yes document details: Functio

way/ anesthesia s nal
complications
status
(MET)

Vital signs: BP(Sys/Dia)= PR= RR= SPO2=

To= Pain score=

Air way MG= TMD= Mouth opening=

assessment Neck mobility= Dentations=

HE Conjunctiv a: Dehydratio Ye No For pediatric age group: <2 sec >2 sec
EN Pink n s capillary refill
T Pale

Cardio vascular Abnormal heart sounds Yes No If yes write :

system heard

Arrhythmias Yes No If yes write:

Cardiac devices Yes No If yes write:

Respiratory Abnormal/decreased/ Yes No If yes what/where?

system absent breath sounds

Abdomen Hepatomegaly/ascite Yes No If yes what/where?

s /tenderness

Genito- urinary Catheterized Yes No If yes UOP= C YES NO

system V
A
T
:

Hematuria Yes No UT Yes No For females LNMP=

I

Musculoskel DVT Ye No If yes write medication:

etal system s

Edema Yes No If yes grade and cause:

Central nervous GCS= Pupillary response= Power: RU= RL=
LU= LL=

system

Electr Na+= K+= Ca+2= C Mg+2=

Investigation
s olytes L
=
CBC BG&RH= HGB= HCT= PLT= WBC= Neutrophil %=

OFT Cr= BUN= ALT= AST= Bilirubin = Albumin=

Endo RBS= HbA1C= TSH= T3= T4= Others=

crine
Coag INR= PT= PTT= Others=
ulatio n

ECG if any

Echocardiography
If any
CXR if any

CT Scan report if any

Final Assessment

Mode of GA GA with GA with IV sedation SpiL/A with LMA sedation with nal
anesthesia ETT mask /Epi

Anesthesia
dur
Plan
al
Medications Yes No If yes document details:
to be hold

Medications Yes No If yes document details:

to be
continued
Premedication Yes No If yes document details:
needed
Blood & Yes No If yes document details:
blood
products
needed
NPO
Time
Post-operative disposition Analgesia plan

Anesthesia evaluator Name= Signature