PREOPERATIVE EVALUATION

Patient: [Name, age, sex]
Date of birth: [Date]
Date of evaluation: [Date]
Requested by: [Surgeon and surgical service]
Evaluating clinician: [Name, credentials; primary care, internal medicine, or pre-admission clinic]
Sources: [Patient, family, chart, specialist letters, pharmacy record]

PLANNED PROCEDURE
Procedure: [Procedure, side, and approach, such as open or laparoscopic]
Date and urgency: [Date; elective, time-sensitive, or urgent]
Expected stay: [Day surgery, or number of nights]
Surgical risk: [Low-risk procedure, or intermediate or high risk]
Bleeding risk: [Low to moderate, or high, as the surgical team classes it]
Planned anesthesia: [General, spinal or epidural, nerve block, or sedation, if known]

HISTORY
Conditions: [Each condition, how well controlled it is, and any recent change]
Cardiac symptoms: [Chest pain, breathlessness, palpitations, fainting, leg swelling, or none]
Past anesthesia: [Previous anesthetics and any problems, such as severe nausea or a difficult airway; family history of anesthesia reactions]
Bleeding history: [Easy bruising, nosebleeds, heavy periods, bleeding after surgery or dental work; family history of a bleeding disorder]
Allergies: [Drugs, latex, chlorhexidine, with the reaction to each]
Substance use: [Tobacco with pack-years, alcohol with amount, cannabis, other drugs]

FUNCTIONAL CAPACITY
Activity: [What the patient does without chest pain or breathlessness, such as climbing two flights of stairs]
Estimate: [4 METs or more, under 4, or unknown; DASI score if used]

RISK ASSESSMENT
Cardiac: [RCRI with the points counted; active cardiac conditions, or none; BNP or NT-proBNP if measured]
Pulmonary and sleep apnea: [Lung disease, smoking, STOP-BANG score and what it means]
Frailty and cognition: [For older adults: frailty scale and cognitive screen with scores; delirium risk]
Other risks: [Kidney, liver, diabetes control, anemia, nutrition, as relevant]
VTE risk: [Score or judgment, weighed against bleeding risk]

EXAMINATION
Vital signs: [BP, heart rate and rhythm, SpO2, BMI]
Heart and lungs: [Murmurs, signs of heart failure, chest findings]
Airway: [Mouth opening, Mallampati class, neck movement, teeth and dental work]
Other findings: [The surgical site, skin, and anything else relevant]

TESTS
Results: [Each test with its date and result]
Not ordered: [Tests considered, and why they would not change management]

MEDICATION PLAN
Continue: [Medicines to take as usual, including on the morning of surgery]
Anticoagulants and antiplatelets: [Last dose by date and time, bridging or none, and the restart plan]
Diabetes medicines: [SGLT2 inhibitor last dose; insulin and other changes]
GLP-1 receptor agonists: [Plan under the anesthesia team's current guidance]
ACE inhibitors and ARBs: [Hold or continue, and when to restart]
Supplements: [What to stop, and from when]

ASSESSMENT AND RECOMMENDATIONS
Summary: [Age, key conditions, procedure, and overall risk in one or two sentences]
Recommendation: [Proceed as planned, optimize first, or delay, with the reasons]
Before surgery: [What to treat or adjust, and by when]
During and after surgery: [Anesthesia flags, monitoring, troponin if indicated, delirium precautions]
VTE plan: [Mechanical or drug prophylaxis, timing, and who orders it]
Communicated to: [Patient and family, surgeon, anesthesia or pre-admission clinic, regular clinician, specialists]

Signed: [Clinician name, credentials, date and time]