Pre-Operative Review Form

This form has been carefully created by AGES for our members

Pre-Operative Review

Patient Details
Name*
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 Details
Planned 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 Background
Previous abdominal surgery
Previous other surgery
Parity
Family complete / Fertility issues
Obstetric / Gyn History
Medical co-morbidities

Medications

Relevant social issues
Recent Examination / Investigation Findings
Last examination date
DD slash MM slash YYYY
Height (cm)
Weight (kg)
BMI
Pelvic & Abdominal examination
Ultrasound 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 Issues
Investigations ordered not yet available
Investigations to be arranged
Pre-admission Clinic Required?
Anaesthetic issues
Expected date of discharge
DD slash MM slash YYYY
Specific discharge plan
Other
Surgical Planning
Name
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 plan
Post-op review of surgical plan / learning goals
Email address of surgeon completing form*

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