Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Post-Operative Assessment Form
Your information
Full Name *
Procedure Performed
Surgery Date
____ / ____ / ________
Pain Level (0-10 Scale)
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Wound/Incision Status
Vital Signs
Mobility Assessment
Additional details
Nausea/Vomiting Assessment
Fluid Intake
Medication Compliance
| Medication | Dose | How often |
|---|---|---|
Drain/Catheter Status
Discharge Readiness Checklist
Follow-Up Appointment
____ / ____ / ________
Provider Signature
Date
Post-Operative Assessment Form template from formisoft.com. formisoft.com/intake-templates/post-operative-assessment