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Pac Form

This document is a pre-anesthesia assessment form containing information about a patient such as their medical history, current medications, physical examination findings, lab results, anesthesia plan, and consent details. The form collects extensive information to evaluate patient risk and plan anesthesia for an upcoming procedure.

Uploaded by

Abhishek Lonikar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
2K views1 page

Pac Form

This document is a pre-anesthesia assessment form containing information about a patient such as their medical history, current medications, physical examination findings, lab results, anesthesia plan, and consent details. The form collects extensive information to evaluate patient risk and plan anesthesia for an upcoming procedure.

Uploaded by

Abhishek Lonikar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PRE-ANESTHESIA ASSESSMENT FORM

Name: Diagnosis:
IPD/MRD No. Age/Sex Procedure planned: On Date:
Ward Bed no. Department: Body Wt Kgs Height BMI

Summary Of Medical History:

Previous Surgery Year Type of Anesthesia Complications/Problems Family Hx Ansthesia Complication  Yes  No.
If Yes, Describe
 Allergy
Alcohol: None  Occasional  Regular
Current Meds Smoking: Pack/day yrs  Stopped
Drug Abuse:

Physical Examination / Systemic reviews


O
Vital signs: Temp C, RR /min. BP / mmHg, Pulse /min. SPO2 % (FIO2 ) Pallor
Airway: Mouth Opening  Nil . Limited.........fingers. Neck movements:  Nil  Limited OSA  Nil  Mild  Severe
Malampati: 1 2 3 4 Thyromental cm Neck mass:  Yes No. If Yes

Potential Dental Damage: 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 O Missing. Patient Informed  Yes  No


Dentures  Yes  No 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 ⃝ Loose. Expected difficult airway  Yes  No
Neuro: Mental status:  Normal  Impaired  Previous CVAs  Seizures. Syncope:
 Weakness  Myopathies: Chronic pains:  Others:
Cardiovasculars: NAD  HTN.. well controlled,  poorly controlled  IHD  Arrhythmias:
 Heart Failure: NYHA Class  Dyslipidemias Palpitation. LVEF % Valvular dis:
 Others
Respiratory:  NAD  COPD  Asthma  Recent URI  TB  Cough  Dyspnea  Others
Auscultations: Heart: Lungs:
 NAD  GERD Jaundice Cirrhosis  Others:
Gastrointestinal:
Renal:  CRF: CCr ml/min.  ESRD  Dialysis  Others
Endocrine:  NAD  DM Type 1 / 2 HB 1c Thyroid:  Normal Hyperthyroid  Hyopthyroid  Adrenal
 LMP Others:
Lab: CBC Date: / / / Boichemistry
/ date / / Coagulation date / / Other Labs:

PTT PT
APTT INR.

CXR ECG
Other Investigations:
Consultation  Yes  No. If Yes Consultation:
Accepted  Not accepted  Reason
ASA: ( Circle) 1 2 3 4 5 E Anesthesia Plan:
Risk, Benefit, Alternatives discussed with  Patient  Parents, Who agreed plan  Yes. No. Name and Relationship to Patient
Consent:  Normal  Moderate Risk  High Risk. Risk:
Arrange blood component:  PRC Units,  Whole Blood Units FFP Units Platelets Units. Book ICU / HDU  Yes No
Pre-op Advice and Pre-meds:

PAC done by: Sign Date

I have reviewed the above information and reassessed the patient which reveals:

Name Sign Date

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