CP Clearance Form

OSPITAL NG MAYNILA MEDICAL CENTER

DEPARTMENT OF MEDICINE AND ICU
PRE OPERATIVE EVALUATION (for patients from Department of Surgery)
Date*

MonthDayYear
LAST NAME
FIRST NAME
Middle Name
Age*
Sex*

MaleFemale
Preoperative Diagnosis*
Type of Operation*
Projected Duration*
Surgeons-in-charge*
Type of Anesthesia*
PAST MEDICAL HISTORY
Past Hospitalization
Past diseases

HypertensionThyroid diseaseHeart diseaseBlood dyscrasiaAsthmaSeizureDMStrokeTuberculosisPneumoniaRenal DiseaseHepatitisOther
Details of Past Medical History
Present Medications
PERSONAL SOCIAL HISTORY
Smoker*

YesNoWith history of smoking
Pack years
Alcohol intake

YesNo
Details of alcohol intake
Amount/frequency
Drug Use

YesNo
Details on drug use
Type/amount/frequency