""•otMfll o.tl:lQCOI!. •tlMt Wt b01 Olleztw'or OftM
s-
Patltr.il ID No
F
o
D OB
AdClteU
NKSNe
Sh.
SEDATION
ASSESSMENT
II Assessment Date
'Fem.a
p..,-.,
Assessed by
I
SocialH
istory
Re
levant Detas
Age/Occupation
Smoking/Alcohol
Medical Conditions
Re
levant Detans
Cardiovascular disease
Respiratory disease
Hepatic/Renaldisease
Bleeding/Epilepsy/D
iabetes
Anaemla/Jaundice/Hepatltis
Other Serious Illness
Operatiol\/GA/Sedation
Drug Therapy
Drugs/Med
icalion
Allergies
Vital Signs
Weght
(kg)
ASA Class
HeighI
(m)
BMI
(kg/m2)
Blood
pressure
Pulse
Respirat on
Rate
Ii Clinlclan Signature
ii