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Elective Surgery Programme Implementation Support Guide

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APPENDIX 5 - SAMPLE PRE-ADMISSION ASSESSMENT FORM<br />

(For completion by pre-admission assessment nurse)<br />

Date of Assessment ………………………………….<br />

Weight:<br />

_______________ Kgs<br />

Height: (spinal anaesthetics only):<br />

Blood Pressure:<br />

Pulse:(/min)<br />

Peak Flow (if relevant): Temp:<br />

Urinalysis:<br />

LMP: N/A<br />

Gravidex Sent Today: Yes No<br />

Glucometer (if relevant)<br />

SPO²:<br />

Smoker: Yes No<br />

Per /day:<br />

Referral to smoking Cessation<br />

Yes No<br />

Alcohol Intake _______ approx per week<br />

Dentures / Crowns / Loose Teeth / Own<br />

Top Bottom<br />

57 Model of Care for <strong>Elective</strong> <strong>Surgery</strong>

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