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Care home pre admission assessment template

Pre admission assessment form 2026

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The document is a preadmission assessment form for patients undergoing surgery at a medical center. It collects essential patient information, including personal details, medical history, allergies, and anesthesia type. The form also includes a system review for various health conditions, smoking and substance use history, and pre-operative instructions. Additionally, it addresses emergency contact information and patient rights regarding advance directives.

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Click ‘Get Form’ to open the pre admission assessment form in the editor.
Begin by entering the patient's name, date of procedure (DOP), and surgeon's name in the designated fields. This information is crucial for identifying the patient and their upcoming procedure.
Select the interview source by checking the appropriate box (Patient, Spouse, Parent, Other). This helps clarify who provided the information.
Fill in contact details including home phone, cell number, and business phone. Additionally, provide age, height, weight, and BMI to give a comprehensive overview of the patient's health status.
Indicate any allergies or reactions by referring to the medication/allergy sheet. Document past surgical history and any personal history of anesthetic problems as applicable.
Complete the medical history section by checking all relevant conditions under system review. Ensure that you provide accurate details for each category listed.
Finally, review all entered information for accuracy before saving or submitting your completed form through our platform.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (123 Votes)

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What is a pre-admission screening?

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Pre admission assessment form 2026

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