PRE ANAESTHETIC EVALUATION RECORD

Date:

NAME: AGE/SEX: WT: CR NO.:

DIAGNOSIS PROPOSED SX:

HISTORY
Fever CAD/IHD/MI Cyanosis Dyspnea Gr.I II III IV DVT/CRAMPS
Cough/Cold Chest Pain Smoking ExerciseTol.:Good/ Avg/ Poor
Epectoration Palpitation Alcohol Neck/Back Problem
SOB: CHF Arthiritis Liver Disorder
Tuberculosis Oedema Polio Jaundice
Pneumonia Hypertension Renal Disorder Bleeding disorder
Asthma/COPD Diabetes Dialysis Family H/O bl.dis.
OSA Stroke./CVD Thyroid Disorder H/O Bld.Transfsn
Allergy Convulsion Alt Mental Status Hoarsness of Voice
Pregnancy Fainting Paralysis Pacemaker
Any drug therapy:
Previous illness:
Previous Anaesth. & Surg.

GENERAL EXAMINATION

Pulse bpm Jaw Movement

B.P. mmHg Neck ROM
R.R. cpm TMD
Temp. Mallampati
Pallor Neck Crm M=missing ,L=loose,
Clubbing Airway C=cap/crown ,X=chipped
Jaundice Intubation Diff. Denture : U L
Cyanosis Veins

SYSTEMIC EXAMINATION
Ressp. S.
C.V.S
C.N.S
G.I.T
Spine
INVESTIGATION
Hb/Hct Bl.Urea S.Elect Blood Grp
TLC S.Crt LFT HIV
DLC Bl.Glu TFT: TSH T3 T4 HBsAg
Plts PT ABG: pH PCO2 PO2 HCO3 Anti-HCV
INR PFT
X- Ray Chest ECG

REMARKS : Including special investigation,fitness status & problrm etc.

Accepted in ASA Gr. I II III IV V R/ E

OTHER INSTRUCTIONS PREANAESTHETIC ADVICE

1. W/I Consent
1 2. Nil orally
2 3. Blood requires units
3 4. Premedication
4 a.T.Pantaparazole 40 mg H.S/MOS
5 b.T.Anxit 0.25 mg HS/MOS

The risks,benefits, alternatives of GA,Reg,&Loc,Sedatives have been discussed

The plan is: GA / Regional / IV Sedation / TIVA / MAC NAME & SIGNATURE OF THE ANAESTHESIOLOGIST
and /or………
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