ENDLESS MOUNTAINS HEALTH SYSTEM Patient Label/Name/DOB/MR#

MONTROSE, PENNSYLVANIA
Pre-Anesthesia Consultation
Procedure: Age: M/F
Procedure/Site/Patient ID Verified ASA CLASS: 1 ! " # $ NPO S%A%&S: Greater than hours
ALL$R'($S:
Pertinent PM)/PS): Acti*it+ tolerance:
Tobacco - ppd X yrs Quit -
EtoH Rec Drus
Snore/!S" "sth#a $!PD Recent %RI

HT& $"D $V"/TI" "rrhyth#ia $H'

D( GERD
)idney Disease *Stae+



Ane,t-e,ia Com.lication,, &!&E P!&V !ther

Pertinent PS),

Diagno,tic, Re*ie/ed Pertinent re.ort,: )gb Plt Coag
C0R: 1 B&N/Cr
AB': O%)$R:
$1': $c-o: $F:
$2am
3S: BP )R OSat Re*ie/ed RN Record )eig-t 4eig-t BM(
)eart: Lung,: Neur:
Ot-er:
A(R4A5 $0AM: Mallam.ati 1 ! " %M Di,tance 6cm7: 1 ! "
Nec8 and 9a/ mobilit+: Normal Re,tricted 6de,cribe7:
Dentition: -oose teeth .ro/en/(issin teeth Poor dentition Denture

AN$S%)$S(A PLAN: Genera0 "nesthesia/TIV" ("$ Spina0/Epidura0 "nesthesia Reiona0 b0oc/
!THER, In1asi1e (onitors &er1e .0oc/ for Post !p Pain by Sureon Re2uest
PRE(ED,
I ha1e discussed the anesthesia and pain #anae#ent p0ans3 inc0udin pertinent ris/s3 co#p0ications and a0ternati1es 4ith the patient
and/or responsib0e party5 Infor#ed consent ac/no40edin this discussion is sined and on chart5
Patient6s fa#i0y 4as present for this discussion5
"00 2uestions fro# the patient 4ere ans4ered5
Current Medication,:
e("R re1ie4ed *if app0icab0e+
Preop .eta .0oc/er *..+ &! 7ES
LAS% DOS$ OF BB: 6i: 5$S7
mg ;










ENDLESS MOUNTAINS HEALTH SYSTEM Patient Label/Name/DOB/MR#
MONTROSE, PENNSYLVANIA
Pre-Anesthesia Consultation
Signature6,7: MD/DO/CRNA Date: %ime: