About this template
The Pre-Op Clearance Form template streamlines the critical process of preparing a patient for surgery. Designed for hospitals, outpatient surgical centers, primary care physicians, and pre-operative clinics, this form organizes the collection of essential patient medical history, current medications, drug allergies, and vital signs. It helps surgical teams assess potential risks and document official physician clearance prior to any procedure.
Using Doc2Form, healthcare providers can instantly convert documents or build structured intake pathways to coordinate seamless communication between surgeons, anesthesiologists, and primary care providers. Capturing complete medical histories and surgical readiness information in an organized Google Form ensures that all pre-op requirements are met safely and efficiently, supporting better patient outcomes and minimizing administrative friction in busy medical practices.
Key features
- Collect comprehensive medical history and current medication lists securely.
- Document vital signs, physical exam findings, and surgical clearance status.
- Streamline communication between primary care providers and surgeons.
- Standardize preoperative evaluations across clinics and hospitals.
Use cases
Outpatient surgical center patient intake and clearance tracking.
Primary care physician sign-offs for elective orthopedic or general sā¦
Primary care physician sign-offs for elective orthopedic or general surgeries.
Pre-anesthesia evaluation and health status screening.
What this form collects
- Full Legal Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Format: MM/DD/YYYY
- Scheduled Date of Surgery (Date)Enter the date your procedure is scheduled to take place.
- Primary Diagnosis (Short answer)State the medical condition requiring surgery.
- Proposed Surgical Procedure (Short answer)Name the specific surgery or procedure being performed.
- Attending Surgeon (Short answer)Enter the full name of the surgeon performing the procedure.
- Significant Medical History (Paragraph)List any chronic conditions, previous surgeries, or major illnesses.
- Current Medications (Paragraph)List all prescription medications, over-the-counter drugs, and herbal supplements you currently take, including dosages.
- Known Allergies (Paragraph)List any allergies to medications, latex, adhesive, or food. If none, write 'None'.
- Blood Pressure (BP) (Short answer)Enter the most recent blood pressure reading (e.g., 120/80).
- Heart Rate (HR) (Short answer)Enter beats per minute.
- Cardiovascular Status (Short answer)Describe findings or note if normal/unremarkable.
- Respiratory / Lungs Assessment (Short answer)Describe lung sounds and respiratory effort.
- Neurological & Psychological Status (Short answer)Note orientation, cognitive function, or relevant neurological findings.
- Preoperative Findings & Summary (Paragraph)Summarize key clinical findings and readiness for anesthesia/surgery.
- Surgery Clearance Status (Multiple choice)Select the appropriate clearance determination.
- Physician Signature / Authorization (Short answer)Please paste a link to your signed document or type your full name and credentials to verify this clearance.
FAQ
How do I customize this pre-op clearance template?
Once your template is generated as a Google Form, you can freely add, remove, or edit any questions directly in your Google Forms editor to match your facility's protocols.
Can patients complete this form on their mobile phones?
Yes. Google Forms are fully responsive, allowing patients to fill out their medical history and consent details conveniently from any smartphone, tablet, or computer.
How do I share this form with patients before their appointment?
You can easily share the Google Form via a direct link in an email appointment reminder, embed it on your practice website, or send it via your patient portal.
Can I export the clearance data for our medical records?
Yes. All form submissions are automatically saved to a linked Google Sheet, making it simple to review responses, export data, or attach summaries to your electronic health record system.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.