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 by Surgery DetailsPlanned procedure* Date of procedure* MM slash DD slash YYYY Allocated OT time (mins) Consultant for OT list Indication for procedure Primary surgeon Assisting or supervising surgeon Patient BackgroundPrevious abdominal surgery Previous other surgery Parity Family complete / Fertility issuesWanting future fertility not actively tryingWanting future fertility actively tryingFamily complete no permanent contraceptionObstetric / Gyn HistoryMedical co-morbidities Medications Relevant social issues Recent Examination / Investigation FindingsLast examination date DD slash MM slash YYYY Height (cm)Weight (kg)BMIPelvic & Abdominal examinationUltrasound Date DD slash MM slash YYYY Ultrasound Findings Cervical Screening Tests Date DD slash MM slash YYYY Cervical Screening Tests Findings Urodynamics Date DD slash MM slash YYYY Urodynamics Findings FBC / Serology Date DD slash MM slash YYYY FBC / Serology Findings Tumour Markers Date DD slash MM slash YYYY Tumour Markers Findings Other Date DD slash MM slash YYYY Other Findings Pre-Op / Admission IssuesInvestigations ordered not yet available Investigations to be arranged Pre-admission Clinic Required?NoYesAnaesthetic issues Expected date of discharge DD slash MM slash YYYY Specific discharge plan Other Surgical PlanningName First Last DOB DD slash MM slash YYYY Planned procedure Date 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
