Operation Planed : __________________________________________

Diagnosis : __________________________________________

PAC (PreAnesthetic Checkup)

Medical History __PAC_MEDICAL_HISTORY__

Allergy Yes / No  

O/E - General Condition - Mod / Fair / Poor

__PAC_OT_INVEST_BLOCK__
Pulse 
BP__PAC_OT_BP__
RR 
RS 
CVS 
Spo2 
ASA 

Intra Operative Monitoring

Type of Anesthesia – MAC / LA / Sedation / GA without ETT / GA with ETT

__PAC_ANESTHESIA_BLOCK__

O/E - General Condition - Mod / Fair / Poor

Pulse 
BP__PAC_OT_BP__
RR 
RS 
CVS 
Spo2 

Medicine given__PAC_MEDICINE_GIVEN__

Post Operative Monitoring

Pulse 
BP__PAC_OT_BP__
RR 
RS 
CVS 
Spo2 

Remark__PAC_OT_REMARK__

Patient Is Fit For Discharge

Name Of Anesthesiologist  
Sign  
__PAC_POSTOP_DOA__