Professional Documents
Culture Documents
PRE-ANAESTHESIA ASSESSMENT
Name
Date Ward
/ / U.R.
Patient
Weight ..............kg Height ............cm BMI ................ Doctor
Patient Identification Label
BP ......... / ......... Pulse .............. Resp ..............
Temp ................
ASA Status (1-6) Gastric Reflux Risk
Fasting Status
Last Food Last Fluid Low Medium High
E
Previous Anaesthesia History/Problems
PL Adverse Drug Reactions
Dental Status
M
SYMBOL LEGEND
Smoking Alcohol
Br Bridge
Ch Chipped
Examination Including Airway
Cr Crown
I Implant
p partial
SA
D DENTURE
c complete
G Gingivitis
Investigations L Loose
M Missing
P Pyorrhoea
S Splint
V Veneer
ANAESTHESIA
Anaesthesia Planned
Local Sedation
Surgeon(s)
Monitoring Time
200
E
140
Other: ................................
Vascular Access 120
IV
IV 100
ART
CVC
Other : ......................................
Ventilation
SP
IPPV
IMV
Airway Device & Size
LMA
ETT
80
60
40
20
10
PL
Other: ....................................... 5
Patient Care
M
Eyes 0
Teeth ETCO2
Pressure Areas
SaO2 (%)
Fluid Warmer
FiO2
Warming Blanket
Position BIS
Calf Compression ET AGENT (%)
ANAESTHESIA
Signature Date / /