ANESTHESIOLOGY PRE-OP EVALUATION

& exovsrts
Covenant Mtdiml tamer
Heighl

Medlcaiions: (Ctrcle Rx Givefi Today)

|**] Note(s) reviewed

Prior Anesthesia Complications: O No O Yes 1s] HD MH O PONV Family Hirforj/ Of Anes. Problems:
@ DTFF Aiway Hx
Q Asthma Q Pneumonia Q Home O, @ Rhinins
Labc WHC HfH f PLT Antitxxly screen + •-
COPD @ Recenl URIQ Sleep Apnea @ CPAP
Na K BUN Cr Glu BTLfTAH LMP
PTfPTT / INR HCG NEG
Q Hiatai Hernia Q Jaundice GI Bleed
@ GERO'PUO Q Ascites Q Cirrhosis
Bridges U / L Neck ROM
@ Diverilcidosls @ Crohn’s Ds @ Appendicitis
OK Limited
HepaHtis [°*) Choiecysfitis
Airway Class: TMD
Exam of Heart Q Regular Q Irregular Q Munnur ONC {°°) WNL Mastectomy R f L Radialion
Exam of Lungs CTA Q Wheeze Q Crackles Q Oiher {**j Chetno {**j Cancer

CAD M1 HX HX CABG @ Hx UTI Q stones Q Acute Reaal Failure CKD

{°°) MVP/MiUAifAS [°°) High Chol [**} AICD/Pacer Henao-Dialysis
@ PVD @ Murmur @ Rh. reset @ BPH @ Peritoneal malysis
@ Arrhythmias (A-Fib/A-Stutter) @ CaldionJyopathy
UNDO, WNL @ NIDDM @ ADDM @ Neuropallty
@ CHh (Systo1ic / DiastoJic) (Acufe / Clzzonic)
@ Obesity @ Hypoglycenzia
Q Thyroid (Hypo/Hyper) O tlierine Dysfurirtlun
EKG:
{_) Bleeding Dysfunction j Hx DVT / PE
CNS (°°] WNL {°°) Dementia {°°) Seizure/Epilepsy ETOH
@ Anemia Chronic @ H1V/A1HS
Q Hx CVA/TlA @ Headaches/Migraines Q Orug Ahuse.
(**} Acute Blood lms Anemia (°°} Sickle Ceil
@ Anxiety @ Depression @ Mentally Impaired
DS fi Eaxy bruisirig/frcq. No ebleeds
Q Residual Heinipa •iiWeinlplegia Q Bipolar
Othal O MalnuDition Q Glaucoma
{**| Decubirris LfJcer Sire
O Back paiii/kower extremity nutnbnexs/wealuitss
@ Transplant stahis (KJdztey/Liva/Heart/Luztg)

Mimcnhiskeietal:
Prenulure V / N hy weeks
(°°} WNL [°°) RA (°°} OA DID [°°) SLE
Hx of apnea Y f N Immunization up-to-date Y N
Gout Arthritis Fihmn1y *8 ia
Hx of intu6ation/respiratory distress Y / N
Preop evaluatlon Signatures: CRNA Anesthesiologist

Plan Of Care: ASA 1 2 3 4 5 E

@ GA @ Combined @ Epiduml @ SAB @ Bier Birk @ Mac @ defused Egidumt/Spinal
Invasive I mcedures DiscuiW.
Q A-Line @ CVC Q PAC TEE @ Bl‹xxl Transfusion
Patil CattroJ Discussed:
@ Epidural @ ISB @ FNB @ @ Refused
CRNA providing anesthesia Signature DaiefTime
Anesthesia plans discussed with CRNA Supervising Anesthesiologist Signature Datemrrie

If pre anesthesia evaluation is completed greater then 48 hours prior to surgery, I

have reviewed and agree with the pre-op evaluation with the following changes:
Patient Identlficadon
Signature

Form 0: 0018 Originated 5f 1/08 Revised 6fl0/IO