Surgical Clearance Form
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1Surgical Clearance Form
Patient
Name:
DOB:
Phone:
Email:
Address:
Pre-Op Date:
Surgery Date:
Diagnosis:
Surgery Rec:
Anesthesia:
Dosage:
Patient History
Medical History:
Surgery 1:
Date:
Surgery 2:
Date:
Surgery 3:
Date:
Medication 1:
Dosage:
Medication 2:
Dosage:
Medication 3:
Dosage:
Allergies:
Other Medical Conditions:
Examination
Height:
Weight:
BMI:
Temp:
Pulse:
BP:
RR:
HEENT:
Neck:
Heart:
Lungs:
Abdomen:
Extremities:
Labs:
X-Rays:
EKG:
U/A:
Results
q The patient is cleared for surgery
q The patient is NOT cleared for surgery
q Further tests required
Signature
Date
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Parent category: Medical