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 YYYYAge (in years)MRN*Date of Clinical Review* MM slash DD slash YYYYLast review bySurgery DetailsPlanned procedure*Date of procedure* MM slash DD slash YYYYAllocated 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 YYYYHeight (cm)Weight (kg)BMIPelvic & Abdominal examinationUltrasound Date DD slash MM slash YYYYUltrasound FindingsCervical Screening Tests Date DD slash MM slash YYYYCervical Screening Tests FindingsUrodynamics Date DD slash MM slash YYYYUrodynamics FindingsFBC / Serology Date DD slash MM slash YYYYFBC / Serology FindingsTumour Markers Date DD slash MM slash YYYYTumour Markers FindingsOther Date DD slash MM slash YYYYOther FindingsPre-Op / Admission IssuesInvestigations ordered not yet availableInvestigations to be arrangedPre-admission Clinic Required?NoYesAnaesthetic issuesExpected date of discharge DD slash MM slash YYYYSpecific discharge planOtherSurgical PlanningName First Last DOB DD slash MM slash YYYYPlanned procedureDate of procedure DD slash MM slash YYYYLearning Goals Potential surgical issues Detailed surgical planPost-op review of surgical plan / learning goalsEmail address of surgeon completing form* Δ