Pre-Op Clearance Form
NL Medical Center
Patient Information:
First Name
Last Name
Date of Birth:
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Surgery:
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diagnosis:
Diagnosis
Proposed Surgical Procedure:
Proposed Surgery
Surgeon
Name Surname
Medical History:
Medical History
Medications:
Medications
Allergies:
Allergies
BP:
BP
HR:
Pulse
HEENT:
Heent
CARD/VASC:
Card
Lungs:
Lungs
Abdomen:
ABD
Extremities:
EXT
Neuro / Psych:
Mental Status
Preoperative Findings:
Is this patient cleared to have surgery?
YES
NO
Signature
Submit
Should be Empty: