PRE-OPERATIVE PHYSICAL FITNESS

PLANNING FOR : DATE:

NAME:

AGE:

SEX:

ADDICTION:

ALLERGY:

PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY:

T- P- BP- RS- CVS- SPO2-

HB: HIV: ECG:

WBC: HbsAG: 2D ECHO:

PLATELETS: HCV:

S.CREAT:

SGPT:

RBS:

THIS IS TO CERTIFY THAT THIS PATIENT IS ............FOR OPERATING.

THANK YOU!