Surgical Procedure: __________________________________________
Medical History - HT/DM/TB/Asthma/CAD/CVE/Thyroid problem
Allergy: _____________________ Addictions-Tobacco/Smoking/Alcohol
Past Medical / Surgical History: ______________________________
Medications: 1) _______________________ 2) ___________________
3) _______________________ 4) __________
O/E - GC- Mod/Fair/Poor | Conscious/Oriented
| Pulse | /min | RS | ASA Grade - I / II / III / IVA / E | |
| BP | /mm of Hg | CVS | ||
| RR | /min | SpO2 | % |
MAC/Sedation/GA without ETT/GA with ETT
Anesthesiologist: ____________________
| Pulse | RS | ||
| BP | /mm of Hg | CVS | |
| RR | /min | SpO2 | % |
Conscious / Oriented / Sedated / Drowsy / Responding
| Pulse | RS | ||
| BP | /mm of Hg | CVS | |
| RR | /min | SpO2 | % |
Specific Advice: __________________________________________
Signature of Anesthesiologist & Name