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Pre-Op Clearance Form Template

Streamline Your Surgical Clearance Process with Our Template

Preparing for surgery can be stressful, especially when you need to ensure all necessary health assessments are completed. This pre-op clearance form template is designed to support healthcare providers and surgical teams in gathering essential patient information for surgery. With this customizable form, you can quickly collect medical history, vital signs, and clearance assessments, ensuring compliance with health regulations and improving patient communication. Benefit from reduced paperwork errors, enhanced organizational efficiency, and a smoother patient experience-all while maintaining WCAG-aligned accessibility standards. Explore the live template now.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Sex assigned at birth
Female
Male
Intersex
Prefer not to say
Email address
Mobile phone number
Home address
Emergency contact full name
Emergency contact relationship
Emergency contact phone
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Planned procedure
Reason for surgery (diagnosis/indication)
Surgeon name
Surgical facility
Target surgery date
Planned anesthesia type
General anesthesia
Regional/spinal/epidural
Monitored anesthesia care (sedation)
Local anesthesia only
Unknown
Do you have a responsible adult to escort you home if needed?
Yes
No
Not sure
Not applicable
Please select any conditions you have been diagnosed with
Please Specify:
If other conditions, please list
Have you had a fever, infection, or antibiotic treatment in the last 2 weeks?
Yes
No
Not sure
COVID-19 infection in the last 3 months
Yes
No
Not sure
Chest pain with exertion in the last 6 months
Yes
No
Not sure
Shortness of breath with minimal activity
Yes
No
Not sure
Can you climb 2 flights of stairs without stopping?
Yes
No
Not sure
Not applicable
Previous surgeries and approximate dates
If yes or unsure, describe any anesthesia issues (e.g., difficult airway, malignant hyperthermia, severe nausea)
Problems with anesthesia for you or a blood relative
Yes
No
Not sure
List all current prescription and over-the-counter medications, vitamins, and supplements (name, dose, how often)
Do you take any blood thinners or antiplatelet medicines (e.g., warfarin, apixaban, rivaroxaban, clopidogrel, aspirin)?
Yes
No
Not sure
Medication, latex, adhesive, or food allergies
Yes
No
Not sure
List allergies and reactions (type 'None' if none)
Do you use CPAP or another device for sleep apnea?
Yes
No
Not sure
Not applicable
Could you be pregnant?
Yes
No
Not applicable
Prefer not to say
Height
Weight
Tobacco or nicotine use
Never
Former
Yes - some days
Yes - daily
Prefer not to say
How often do you consume alcoholic drinks?
Very rarely
Rarely
Sometimes
Often
Very often
Recreational drug use in the last 3 months
Yes
No
Prefer not to say
Recent lab results available (within 6 months)
Yes
No
Not sure
Recent ECG or cardiac evaluation available (within 12 months)
Yes
No
Not sure
Not applicable
Implanted cardiac device (pacemaker or defibrillator)
Yes
No
Not sure
Primary care clinician name
Primary care clinic phone
Preferred pharmacy (name and location)
Where can we obtain records or additional notes for your clearance?
Advance directives (e.g., living will, medical power of attorney)
Yes
No
Not sure
I confirm the information provided is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Signer full name
Date signed
I authorize the clinic to obtain and share my medical records with my surgeon and surgical facility for pre-operative clearance.
Yes
No
Evaluating clinician name
Clearance decision
Cleared for surgery without restrictions
Cleared with conditions or recommendations
Not cleared at this time
Refer to specialist
Pending test results
Not applicable
Notes and recommendations
Re-evaluation or follow-up date
Recommended pre-op tests or actions
Please Specify:
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Paper art illustration depicting a Pre-Op Clearance Form Template for FormCreatorAI article

When to use this form

When your clinic needs to document fitness for anesthesia and a planned procedure, use this form to capture history, medications, test results, and the final decision. It helps surgeons, PCPs, and hospital pre-op teams avoid last-minute cancellations and set clear perioperative instructions. Typical uses include elective orthopedic cases, outpatient endoscopy, and urgent but non-emergent procedures. Pull recent records from your EHR, then attach a summary from the Medical chart review form. For programs that issue a formal note to the surgeon, pair this with the Surgery clearance form. If you screen patients in advance, prefill vitals and risk flags from the Health screening form. The outcome is a concise, defensible decision: proceed, optimize, or defer.

Must Ask Pre-Op Clearance Questions

  1. What procedure is planned, when is it scheduled, and who is the operating surgeon?

    This sets clinical context and urgency, so your assessment matches the specific surgical risk. Surgeon details enable direct follow-up to resolve questions before the day of surgery.

  2. What are the patient's active conditions, current cardiac or respiratory symptoms, and functional capacity (e.g., can they climb two flights of stairs)?

    These inputs drive risk stratification and help you decide if further testing or optimization is needed. Functional capacity is a simple, reliable predictor of perioperative risk.

  3. List all medications, including anticoagulants, antiplatelets, and supplements, with doses and last taken time.

    A complete list supports safe hold/bridge plans and reduces bleeding or glycemic complications. Knowing the last dose helps schedule surgery and anesthesia appropriately.

  4. What recent test results are available (EKG, CBC, BMP, coagulation, imaging), and what abnormal findings require action?

    Documented results show readiness and provide a baseline for the OR team. Flagging abnormalities early prevents day-of cancellations and delays.

  5. Do you medically clear the patient for anesthesia and surgery, and what restrictions or optimization steps are required?

    A clear decision, with conditions and timelines, creates a defensible record and actionable plan. If you will set post-op activity limits, coordinate using the Return to work form.

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