1) This document contains a pre-operative assessment checklist for a patient undergoing surgery. It includes patient demographic information, medical history, review of systems, physical examination findings, and lab results. 2) The checklist documents the patient's chronic illnesses, past medical and anesthetic history, social habits, allergies, and family history. 3) Based on the assessment, the patient is assigned an ASA physical status score and recommendations are made regarding pre-operative instructions and medications.

1. ERIC WILLIAMS MEDICAL SCIENCES COMPLEX PART 1
PRE-OPERATIVE ASSESSMENT FOR ANAESTHESIA CHECKLIST
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DATE: ________________ TIME____________ SURGEON: ______________________________________
MEDICAL RECORD #: __________________
SURNAME: ________________________________ OPERATION: ____________________________________
FIRST NAME: _____________________________________
WARD: _________________ ANAESTHETIST:__________________________________
AGE: ________ WEIGHT: _______ HEIGHT: _________ BMI:________kg/m2
BLOOD GROUP: __________
CONSENT FORM SIGNED: YES □ NO □ HEALTH SURVEY QUESTIONNAIRE COMPLETE:YES □NO □
DATE OF LAST MENSTRUAL PERIOD: _____________ BP. / P R T
ILLNESS HISTORY: ______________________________________________________________________________________________
TRAUMA YES□ NO□ LOC YES□ NO□DURATION_________ TIME OF LAST MEAL/DRINK: _____________
VOMITING YES□ NO□ DIARRHOEA YES□ NO□ BLEEDING YES□ NO□ OTHER FLUID LOSSES _______
CHRONIC ILLNESS:
DIABETES YES□ NO□ TYPE IDDM□ NIDDM□ DURATION______ TREATMENT_____________________
HYPERTENSION YES□ NO□ DURATION______ TREATMENT__________________________________________
ISCHAEMIC HEART DISEASE YES□ NO□ DURATION ______ TREATMENT_____________________________
SCD YES□ NO□ TREATMENT__________ THALASSEMIA YES□ NO□ BLEEDING DISORDER YES□ NO□
ASTH MA YES□ NO□ PREV ADMISSION□ PREV ICU□ LAST ATTACK_______ TREATMENT_______________
EPILEPSY YES□ NO□ LAST ATTACK________ TREATMENT__________________________________________
CONGENITAL HEART DISEASE YES□ NO□ RHEUMATIC HEART DISEASE YES□ NO□
OTHER ILLNESSES _______________________________________________________________________________________
PERINATAL HISTORY:
TERM□ PRETERM□ ____/40 COMPLICATIONS DURING PREGNANCY YES□ NO□ SCBU/ NNU YES□NO□
RELEVANT INFO:________________________________________________________________________________
REVIEW OF SYSTEMS:
RECENT URTI (WITHIN LAST 3 WEEKS) YES□ NO□ RUNNY NOSE□ FEVER□ PRODUCTIVE COUGH□
DYSPNOEA YES□ NO□ CHEST PAIN YES□ NO□ PALPITATIONS YES□ NO□ PND YES□ NO□
EXERCISE TOLERANCE ______________________________________ ORTHOPNOEA NO□ YES□______PILLOWS
GASTRO-OESOPHAGEAL REFLUX YES□ NO□ SNORING YES□ NO□ SLEEP APNOEA YES□ NO□
DRUG HISTORY:
ANTIHYPERTENSIVES________________ ANALGESICS_______________ ORAL CONTRACEPTIVE PILL_____________
ANTIDIABETICS ______________________ DIURETICS_________________ ANTICOAGULANTS _____________________
CORTICOSTEROIDS ___________________ ANTIBIOTICS ______________ OTHER_______________________________
HERBAL MEDICINE _________________ BUSH TEAS________________ OTC DRUGS____________________________
SOCIAL HISTORY: SMOKER NO□ YES□________/ DAY MARIJUANA NO□ YES□ COCAINE NO□ YES□
ALCOHOL USE NO□ YES□ OCCASIONAL□ MILD□ MODERATE□ HEAVY□______________
ALLERGIES: NO□YES□_____________ RASH□ URTICARIA□ AIRWAY OEDEMA□ ANAPHYLAXIS□
ANAESTHETIC HISTORY: PREV SX NO□ YES□_____________ PREV HOSPITALISATION NO□ YES□_______________
PREV GA NO□ YES□ DATE_____________ PROBS WITH GA NO□YES□_________PONV □PAIN □
FAMILY HISTORY: ADVERSE REACTION TO PREV ANAESTHETIC NO□ YES_________________________ICU ADMISSION□

2. PRE-OPERATIVE ASSESSMENT FOR ANAESTHESIA CHECKLIST
PART 2
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PHYSICAL EXAMINATION
MUCOUS MEMBRANES: MOIST□ DRY□ PINK□ PALE□ CYANOSIS YES□ NO□ ICTERUS YES□ NO□
AIRWAY ASSESSMENT: EDEMA YES□ NO□ BEARD YES□ NO□ THYROID / AIRWAY MASS YES□ NO□
TEETH CARIES□ LOOSE TEETH□ BUCK TEETH□ CAPS□ CROWNS□
INTERDENTAL DISTANCE: <3FB□ >3FB□ THYROMENTAL DISTANCE: <6.5cm□ >6.5cm□
NECK MOBILITY GOOD: NO□ YES□ STERNOMENTAL DISTANCE: <12.5cm□ >12.5cm□
TMJ MOBILITY: UNABLE TO PROTRUDE JAW□ TEETH JUST TOGETHER□ CAN PROTRUDE JAW□
MALLANPATI SCORE: I II III IV EDENTULOUS: YES□ NO□
LIKELY DIFFICULT VENTILATION YES□ NO□ LIKELY DIFFICULT INTUBATION YES□ NO□
RESIRATORY SYSTEM: TRACHEA CENTRAL YES□ NO□ AIR ENTRY R=L YES□ NO□ CREPITATION□ RHONCHI□
EXPANSION_____________________ PERCUSSION__________________ VOCAL FREMITUS _________________
FINDINGS ON AUSCULTATION_______________________________________________________________________
CARDIOVASCULAR SYSTEM: PULSE RATE ___________regular□ irregular□ BLOOD PRESSURE _______/_______
HEART SOUNDS S1 S2 S3 S4 THRILLS_____________ MURMURS_______________
SIGNS OF CARDIAC FAILURE _________________ FUNCTIONAL DIAGNOSIS __________________________
ABDOMEN: THIN□ NORMAL□ OBESE□ DISTENSION YES□ NO□ ASCITES YES□ NO□
SITE FOR REGIONAL BLOCK: THORACO-LUMBAR SPINE _____________________ UPPER / LOWER LIMB ___________________
VENOUS ACCESS: LIKELY DIFFICULT YES□ NO□ IV IN SITU: FUNCTIONAL YES□ NO□ ADEQUATE YES□ NO□
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INVESTIGATIONS ORDERED & RESULTS
Hb __________ Hct ____________ WBC _________ Platlets __________ PT______________ PTT____________
Na ___________ K _____________ Cl ____________ Urea ____________ Creat ____________ Glu_____________
ECG_____________________________ CXR_________________________________ ECHO_____________________________
Lung Fcn Tests_____________________ PEFR___________________ ABG_____________________________________________
BLOOD GROUPED AND CROSS MATCHED YES□ NO□ OLD REPORTS/NOTES AVAILABLE YES□ NO□
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ASA STATUS: I II III IV V Emergency / Urgent / Scheduled Fit for Day Surgery YES□ NO□
STARVATION ORDERS ________________________________________________________________________________________
PREMEDICATION ORDERED: ___________________________________________________________________________________
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ADVICE:
WITHOLD DIABETIC MEDICATION; ON MORNING OF SURGERY, DO FBS & ELECTROLYTES, START SLIDING SCALE INSILIN
STOP ASPIRIN 2/52 BEFORE SURGERY CONTINUE: ANTIHYPERTENSIVES ON MORNING OF SURGERY
GIVE ASMATHICS SALBUTAMOL BEFORE SURGERY GIVE STEROID TO PTS ON STEROIDS FOR ≥2/52 IN LAST 2 YRS
CONSIDER DVT PROPHYLAXIS AND H2 BLOCKERS FOR OBESE PATIENTS
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ANAESTHETIC OFFICER: ___________________________________