Surgical History Form
Form preview
The Surgical History Form is a focused template for documenting a patient's complete surgical background. Unlike the general medical history form, this template dives deep into surgical-specific details: every prior procedure with dates, surgeons, and facilities; anesthesia type and any adverse reactions; surgical complications including infections, bleeding, and wound healing issues; and implanted devices or hardware.
This form is critical for pre-operative planning and surgical clearance. Anesthesia history is documented with specificity -- previous reactions to general, regional, or local anesthesia, malignant hyperthermia family history, and airway management difficulties. Blood transfusion history includes previous transfusions and any transfusion reactions.
The template also captures current anticoagulant and antiplatelet medication use, which is essential for surgical planning and perioperative medication management. Post-surgical recovery patterns help set expectations for upcoming procedures. This form is used by surgical practices, pre-admission testing centers, and anesthesiology departments across all surgical specialties.
What's included
- Complete surgical history with dates and details
- Anesthesia history and adverse reactions
- Surgical complication documentation
- Implanted device and hardware registry
- Blood transfusion history and reactions
- Current anticoagulant documentation
- E-signature capture
Who uses this template
- Pre-operative assessment clinics
- Surgical practices across all specialties
- Anesthesiology departments
- Pre-admission testing centers
All form fields
9 fields across 2 pages. Customize any field after signing up.
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