Pre-Operative Review Form This form has been carefully created by AGES for our members Pre-Operative Review Patient DetailsName* First Last Date of Birth* DD slash MM slash YYYY Age (in years)MRN*Date of Clinical Review* MM slash DD slash YYYY Last review bySurgery DetailsPlanned procedure*Date of procedure* MM slash DD slash YYYY Allocated OT time (mins)Consultant for OT listIndication for procedurePrimary surgeonAssisting or supervising surgeonPatient BackgroundPrevious abdominal surgeryPrevious other surgeryParityFamily complete / Fertility issuesWanting future fertility not actively tryingWanting future fertility actively tryingFamily complete no permanent contraceptionObstetric / Gyn HistoryMedical co-morbiditiesMedications Relevant social issuesRecent Examination / Investigation FindingsLast examination date DD slash MM slash YYYY Height (cm)Weight (kg)BMIPelvic & Abdominal examinationUltrasound Date DD slash MM slash YYYY Ultrasound FindingsCervical Screening Tests Date DD slash MM slash YYYY Cervical Screening Tests FindingsUrodynamics Date DD slash MM slash YYYY Urodynamics FindingsFBC / Serology Date DD slash MM slash YYYY FBC / Serology FindingsTumour Markers Date DD slash MM slash YYYY Tumour Markers FindingsOther Date DD slash MM slash YYYY Other FindingsPre-Op / Admission IssuesInvestigations ordered not yet availableInvestigations to be arrangedPre-admission Clinic Required?NoYesAnaesthetic issuesExpected date of discharge DD slash MM slash YYYY Specific discharge planOtherSurgical PlanningName First Last DOB DD slash MM slash YYYY Planned procedureDate of procedure DD slash MM slash YYYY Learning Goals Potential surgical issues Detailed surgical planPost-op review of surgical plan / learning goalsEmail address of surgeon completing form* Δ
