Hospital Logo Here

Patient Name  _______________   ID #  _______________  Date  __________     Procedure Planned   __________________________________________________________

Preanesthetic Exam
Signalment:	Over 7 years? Sighthound? Brachiocepahlic?	___ No        ___ Yes    ____________    ___ No        ___ Yes    ___ No        ___ Yes
History:	Heartworm Exam? Liver Disease? Kidney Disease? Other Significant History?	___ OK      ___ Due    ___ No        ___ Yes    ___ No        ___ Yes    ___ No        ___ Yes
Exam:	Mucous Membranes? Lung Sounds Heart Murmur? Arrhythmia? Other Significant Findings? Describe ___________________	___ NI         ___ Pale        ___ Jaundice        ___ Slow CRT    ___ NI         ___ Abnormal    ___ No        ___ Yes    ___ No        ___ Yes    ___ No        ___ Yes

   Weight   __________   Doctor   __________________         ___   Time estimate > 1 hour

Recommendations:
___________________________________________________________________________________
___________________________________________________________________________________

Anesthesia Given:	Antibiotic ____________ Preop/Sedation ____________ Induction ____________ Maintenance ____________	Time: ____________   ____________
Machine Checked by # 1      ______       # 2 _______     Double Checked by              ______           _______
Local Anesthetic ___________________________________

NOTES: