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Name: (Mr. /Mrs. /Miss. /Dr. /Prof.

) ___________

Age: _________________

Sex: (Female/Male)

Contact no: (can add up to two contact numbers)

Address: (drop down list for all areas)

Weight: _________

Height: __________

Blood pressure: _______

Heart rate: ________

Surgery: (Elective/Emergency)

Surgical diagnosis: (B/L advanced knee osteoarthritis/Left advanced knee osteoarthritis/Right knee
osteoarthritis/Left hip AVN/Right Hip AVN/Left hip osteoarthritis/Right knee osteoarthritis/Fracture
Right Neck of Femur/Fracture Left Neck of Femur/ Fracture Right IT of Femur/ Fracture Left IT of
Femur/Others:__________________)

Proposed Operation: (B/L Total Knee Replacement/Left Total Knee Replacement/Right Total Knee
Replacement/Left Total Hip Replacement/Right Total Hip Replacement/ Left DHS/Right DHS/ Left Bipolar
Hemiarthroplasty/Right Bipolar Hemiarthroplasty/Others :___________________)

Implants: (PFC, LCCK, and Zimmer LPS, Attune, J&J other: _________________________)

Co-morbid: (HTN/DM/CKD/HEP-B/HEP-C/
CVA/EPILEPSY/CA/RA/hypothyroidism/hyperthyroidism/Others: ____________)

Anti-hypertensives (YES/NO), Oral Hypoglycemic (YES/NO), Blood Thinners (YES/NO), Insulin (YES/NO),

Medicines: ______________

Previous Surgeries: ____________

Previous history of IA injections: (YES/NO) Any Complication: (YES/NO) Remarks: ___________

Previous use of Antibiotics: (YES/NO) Remarks: ____________

Allergy: ______________

Addictions: (pan/Gutka/Smoker/Hukka/vape/charas/Others: ________)

Sleep: (Disturbed/Sleep Apnea on BIPAP or CPAP/Sleep Apnea no interventions/others: ___________)

Urinary complaints :( Yes/No) (stress incontinence/BPH/Burning) Remarks: _______________

Respiratory issues: (Yes/No) Remarks: _____________

Malampatti Classification: (class I/class II/class III/class IV)


Oral Hygiene: (Good/Fair/Poor)

Teeth: (no implants/no dentures/Implants/Dentures)

Investigations:

CBC:

RBS:

FBS:

HBA1C:

Urea

Creatinine

Electrolytes

LFTS: (WNL/Abnormal) Remarks:

ECG:

Chest XRAY:

Hepatitis B: (Reactive/Non-Reactive)

Hepatitis C: (Reactive/Non-Reactive)

ECHO:

PT:

INR:

APTT:

Urine D/R (WNL/Remarks)

Urine C/S (No Growth/Remarks)

ASA Classifications:

1/2/3/4/5

Anesthesia Plan:

(General/Spinal/Epidural/Regional/Local/Sedation)
Proposed date of surgery:

Assessment date:

Patient Consent signed: (YES/NO)

Assessment done by: (Dr. Shabbir Jumani/Dr. Kamlesh/Dr. Neelam/Others)

Patient to be operated by: (Prof Syed Shahid Noor) others:

Notes: