Medications: please list doses, schedule (e.g. lisinopril 5 mg once daily)


Allergies: Medication, Latex, environmental


Family history: perioperative bleeding/clotting, or problems tolerating anesthesia.


Social history: tobacco, alcohol, illicit drugs, exercise tolerance.


Past Surgical History: surgery type, anesthesia provided (if known). Problems tolerating anesthesia or with bleeding/clotting?


Review of Systems: ability to climb 2 flights of steps or walk 4 blocks.



Cardiac:  Please identify if any of the following are present, and if the condition is stable (controlled) versus unstable (not controlled):

Hypertension, coronary artery disease, valvular heart disease, congestive heart failure (systolic vs diastolic, NYHA Class I to IV, provide left ventricular ejection fraction)

Provide stress test or catheterization results if available.


Pulmonary: Asthma (note severity), COPD, other lung disease.  Provide functional status, ABG’s, PFT’s


Renal: Chronic kidney disease, dialysis history. History/risk of acute kidney injury.


GI: Inflammatory bowel disease (list type). Prior bariatric surgery (if lap band, is it deflated?).

Liver disease (list type and sequelae).  Peptic ulcer disease.


Hematologic:  Anemia (list Hb/Hct and therapy provided). Coagulopathy (list type and prior bleeding/clotting problems).


Endocrine: DM (list type, insulin use, and history of DKA or hyperosmolar syndrome).  Thyroid disease.


Cancer: Type, extent of disease, current physiologic effect on patient (from disease or ChemoRx).


Infections:   Site, organisms, Rx previously provided.


Neurologic: Type, symptoms, physiologic limits to pt.


Musculoskeletal/Rheumatologic: Type, steroid/immunosuppressant history, presence of cervical spine disease complicating intubation.


Psychiatric: depression, anxiety, substance abuse, medication/pain management issues.


Other: List problem and recommendations


Physical Exam: VS, heart, lungs, neurologic, other pertinent.


Data: Pertinent lab results and other studies


Impression: Is patient in his/her optimal medical condition for the scheduled surgery?  Yes or No



Include all perioperative medication adjustments

List any changes recommended to optimize patient’s medical condition

List any recommended perioperative testing