PEMERIKSAAN PRE-OPERATIFNama : ..................................................................RM :....................................Umur :.........................................................................................................................................Jenis Kelamin :.........................................................................................................................Berat badan :................................................Tinggi badan :...................................Kelas :.............................................................Cara Bayar :......................................Diagnosa :..............................................................................................................................Rencana Terapi :...................................................................................................................Operator / DPJP :...................................................................................................................Anamnesis1. Riwayat penyakit yang dapat menjadi penyulit anestesiAsma ( )Hipertensi( )Batuk( )DM( )Penyakit Hati( )Demam( )Alergi( )Penyakit Ginjal( )Pilek( )Angina Pectoris ( )Stroke( )Kejang( )2. Riwayat obat yang sedang / telah digunakanAnti hipertensi( )obat penyakit jantung( )Anti rematik( )obat anti nyeri( )Anti diabetic( )dll...........................................................3. Riwayat operasi sebelumnya : ..................................................................4. Riwayat anestesi : .....................................................................................Pemeriksaan FisikAirway :bebas /tidakFraktur( ),deformitas ( ),tumor ( )Gigi palsu ( ) (pada bayi dan anak tidak dilaporkan)

Breathing:frekuensi ........................., pola napas ..............................................., simetris/tidakBlood : perfusi telapak tangan - (hangat kering merah) - (dingin basah pucat )TD ............................,nadi ....................................., teratur kuat angkatBrain :GCS ..........( E :........, V:..........., M:...........) Bladder :BAK biasa / Menggunakan Kateter (berapa cc / jam)Bowel :mual ( ),muntah ( ),BAB biasa/ berdarahBone :fraktur ( ),udem ( )Labor LengkapTanggal labor terakhir :Hb PT Natrium

Leukosit APTT Kalium

Trombosit UreumKlorida

HT Kreatinin

EKG (>40 tahun) :..............................................................................................................................................Rontgen toraks:................................................................................................................................................ECHO (>60 tahun) :..........................................................................................................................................Puasa : Terakhir makan..................... jam yang lalu, minum:.................... jam yang laluPersedian darah : .................................Kantong (PRC/ WB/...........)Konsul interne: