Pre-Surgery Assessment
Pre-operative assessment covering fitness, anaesthetic history, medication to stop or continue, fasting instructions and arrangements for going home.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 27 questions, 3 pages, 4 conditional rules.
- Questions
- 27
- Pages
- 3
- Layouts
- classic · card
- Time to complete
- ≈ 10 min
- Conditional rules
- 4
Searches this template answers
- pre surgery assessment form
- pre operative assessment form template
- surgery questionnaire form
- pre op health questionnaire
- anaesthetic assessment form
- day surgery assessment form
Also filed under
Live preview and test console
This is the real form. Answer it to test the flow — nothing is sent or stored.
Page 1 of 3 — Procedure and fitness
This template runs as a straight sequence — no branching rules.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
Who this template is for
Pre-Surgery Assessment is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 27 questions across 3 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 17 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It captures a phone number for urgent follow-up.
- It pins the request to a specific date.
- It allows multiple selections without free text.
- It captures a numeric value you can filter and sort on.
- Conditional logic hides 4 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 3 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Pre-Surgery Assessment lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 4 conditional rules ship with it.
- Features conditional validation: if “Have you had an anaesthetic before?” is Yes, “Any problem with a previous anaesthetic?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Are you taking blood-thinning medication?” is Yes, “Which medication, and has anyone advised you to stop it?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Will an adult be at home with you for the first night?” is No, “What arrangements are in place?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Do you have diabetes?” is Yes, “How is your diabetes managed?” becomes mandatory before the form can be sent.
- All 4 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
About this template
Cancelled operations are expensive and almost always avoidable, and the reasons cluster: a medicine that should have been stopped, an anaesthetic history nobody asked about, no lift home, or a patient who ate breakfast. This three-page assessment collects each of them ahead of the date. The first page confirms the procedure, the surgeon and the planned date, then general fitness: conditions, exercise tolerance described in everyday terms such as stairs and walking distance, height, weight and smoking. The second page is anaesthetic and medication history — previous anaesthetics and any problem with them, family problems with anaesthesia, allergies, current medicines including blood thinners and diabetes medication, and anything bought over the counter. The third page is the practical one: who is bringing the patient and taking them home, whether there is an adult at home for the first night, stairs and access, fasting understanding and any dietary or mobility need on the day. Every answer is the patient's report, and the pre-operative team confirms the clinically material ones directly.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
Page 1 — Procedure and fitness
- Full namerequired
- Date of birthrequired
- Procedure plannedrequired
- Surgeon or servicerequired
- Planned daterequired
- Medical conditions you have
- Can you climb two flights of stairs without stopping?required
- Height in centimetres
- Weight in kilograms
- Do you smoke or vape?required
Page 2 — Anaesthetic and medicines
- Have you had an anaesthetic before?required
- Any problem with a previous anaesthetic?
- Has anyone in your family had a problem with anaesthesia?required
- Allergies and what happens on exposure
- All medication you take, with dosesrequired
- Are you taking blood-thinning medication?required
- Which medication, and has anyone advised you to stop it?
- Do you have diabetes?required
- How is your diabetes managed?
- Anything bought without a prescription, including supplements
Page 3 — The day itself
- Who is bringing you and taking you home?required
- Will an adult be at home with you for the first night?required
- What arrangements are in place?
- Are there stairs to reach your bed or bathroom?required
- Understandingrequired
- Any mobility, dietary or communication needs on the day
- Best number on the dayrequired
27 questions in total.
Example of a completed pre-surgery assessment
A sample assessment showing how a patient reports fitness, history and home arrangements before a planned procedure.
- Full name
- Beatriz Almeida
- Procedure planned
- Knee arthroscopy
- Planned date
- 15/05/2026
- Can you climb two flights of stairs without stopping?
- Yes
- Have you had an anaesthetic before?
- Yes
- Any problem with a previous anaesthetic?
- None noticed
- Are you taking blood-thinning medication?
- No
- Who is bringing you and taking you home?
- My partner, by car
- Will an adult be at home with you for the first night?
- Yes
Sample data — no real people, addresses or records are shown.
How the form changes as it's filled in
This template ships with 4 conditional rules, grouped into 4 behaviours driven by 4 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Have you had an anaesthetic before?”
- Makes answers required
If “Have you had an anaesthetic before?” is Yes, “Any problem with a previous anaesthetic?” becomes required before the form can be submitted.
Driven by “Are you taking blood-thinning medication?”
- Makes answers required
If “Are you taking blood-thinning medication?” is Yes, “Which medication, and has anyone advised you to stop it?” becomes required before the form can be submitted.
Driven by “Will an adult be at home with you for the first night?”
- Makes answers required
If “Will an adult be at home with you for the first night?” is No, “What arrangements are in place?” becomes required before the form can be submitted.
Driven by “Do you have diabetes?”
- Makes answers required
If “Do you have diabetes?” is Yes, “How is your diabetes managed?” becomes required before the form can be submitted.
Set it up step by step
- 1
Ask fitness in everyday terms
Two flights of stairs and a walking distance tell an anaesthetist more than a patient's estimate of their own fitness ever will.
- 2
Chase the medication answers first
Blood thinners and diabetes medication are the two most common reasons a planned list is disrupted, so triage those submissions immediately.
- 3
Confirm the lift home before the date
No responsible adult at home is a same-day cancellation, and it is discovered a fortnight early by asking here.
- 4
Restate fasting rules in writing
The checkbox records understanding; send the actual times separately and close to the date, when they will be read.
Mistakes to avoid
- Assuming a patient will mention a previous anaesthetic problem without being asked directly.
- Collecting a medication list with no doses, which cannot be acted on before the list is drawn up.
- Leaving transport and overnight support to the day of surgery.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Triage assessments by medication and anaesthetic answers, contact anyone whose arrangements are incomplete, and confirm fasting and arrival times in a separate message before the date.
Works in both layouts
Forms that overlap this one
These pages cover the same subject ground as the pre-surgery assessment, matched on the words people actually search for.
Occupational Health Form
assessmentclinicclinicalcoveringfitnes
Discharge Follow-Up Form
clinicclinicalcoordinatorcoveringhealth
Home Health Assessment
assessmentclinicclinicalcoordinatorhealth
Sleep Study Intake Questionnaire
assessmentclinicclinicalcoordinatorcovering
Fall Risk Assessment Form
assessmentclinicclinicalhealthhistory
Nutrition Intake Form
assessmentclinicclinicalcoveringday
Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
Does this replace consent for the operation?
No. Consent is a separate conversation recorded with the Consent to Treatment Form; this assessment establishes whether the patient can proceed safely and what needs arranging.
Should the form tell patients when to stop medication?
No. It flags what they take so a clinician can give instructions; automated stop advice from a form is not safe and should never be built into it.
How far ahead should it be sent?
Far enough that a flagged medicine or a missing lift home can be resolved without moving the date — usually two to three weeks before the procedure.
Is it suitable for day surgery only?
It works for both. The third page matters most for day cases, where going home the same evening depends on the arrangements it asks about.
Is the Pre-Surgery Assessment template free to use?
Yes. You can preview and test Pre-Surgery Assessment on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Pre-Surgery Assessment template ask for?
It asks 27 questions across 3 pages, 17 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Pre-Surgery Assessment form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
4 conditional rules ship with the template: Features conditional validation: if “Have you had an anaesthetic before?” is Yes, “Any problem with a previous anaesthetic?” becomes mandatory before the form can be sent. Features conditional validation: if “Are you taking blood-thinning medication?” is Yes, “Which medication, and has anyone advised you to stop it?” becomes mandatory before the form can be sent. Features conditional validation: if “Will an adult be at home with you for the first night?” is No, “What arrangements are in place?” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.
Where do responses to the Pre-Surgery Assessment form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Pre-Surgery Assessment form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
Related templates
More forms teams pair with the pre-surgery assessment.
Related categories
Patient Intake Questionnaire
Pre-appointment intake in two parts: contact and cover details, then reason for attending, current medication, allergies and relevant history.🏥 Healthcare & Clinical18 questionsShort form — 18 questions across 2 pages.View templatePatient History Form
Full three-part medical history: personal and family background, systems review, lifestyle and medication, ready before a first consultation.🏥 Healthcare & Clinical24 questionsMedium length — 24 questions across 3 pages.View templateMental Health Intake Form
Three-page intake for mental health services: presenting concerns, history and support, risk and safety questions, and what the client wants from therapy.🏥 Healthcare & Clinical25 questionsMedium length — 25 questions across 3 pages.View templateNurse Triage Form
Clinician-completed triage record: the presenting problem, observations taken, red flags checked, the advice given, and the disposition decided.🏥 Healthcare & Clinical17 questionsShort form — 17 questions across 2 pages.View templateQuick Symptom Report
Short between-appointments update: what the patient is noticing now, since when, how it is affecting daily life and whether they want a call.🏥 Healthcare & Clinical11 questionsShort form — 11 questions on a single page.View templateQuick Vaccination Record
Short record of a vaccination given: patient, product and batch number, site and date, plus who administered it and any observation in the minutes after.🏥 Healthcare & Clinical14 questionsShort form — 14 questions on a single page.View template
