SOAR Pre-Op Report

Patient Demographics

Full Name

Date of Birth

ID / Passport Number

Gender

Contact Number

Medical Aid / Fund

Referring Surgeon

Vitals & Measurements

Systolic BP

mmHg

Diastolic BP

mmHg

Heart Rate

bpm

Weight

kg

Height

cm

BMI

kg/m²

O₂ Saturation

Temperature

Planned Procedure

Surgical Procedure

ICD-10 Code (optional)

Surgery Date

Urgency

Anaesthetic Type Planned

Surgical Goals / Special Notes

Medical History

Significant Past Medical History

Current Medications

Known Allergies

Previous Anaesthetic Issues

None

Yes — specify

Functional Assessment Prehab Focus

Functional Capacity (METs)

Pain Score (0–10)

Pain Location / Description

Nutritional Status

Mobility / Gait

Cognitive Status

Social Support / Living Situation

Frailty & Anaesthetic Risk

Frailty Classification

—

Not assessed

Complete functional assessment to generate score

ASA Physical Status Classification

IHealthy

IIMild systemic disease

IIISevere systemic disease

IVLife-threatening

VMoribund

VIBrain dead / organ donation

Cardiac Risk (Revised Cardiac Risk Index)

Additional Risk Factors

Active smoker Obesity (BMI >30) Diabetes (poorly controlled) COPD / respiratory disease Cardiac disease / previous MI Renal impairment (eGFR <60) Anticoagulant therapy Previous DVT / PE

MDT Referrals & Prehabilitation Plan MDT

Referrals Made

Dr V Davidoff (GP)

Dalya Hockman (Dietitian)

Daniella Sher (Biokineticist)

Sarah Harrison (Music Therapist)

Dr T Blumenthal (Anaesthetist)

Dr Tarin Penberthy (Pain Specialist)

Physiotherapy

Psychology / Social Work

Cardiology

Respiratory / Pulmonology

Exercise Prescription

Nutritional Plan

Smoking / Alcohol Cessation

Psychological / Wellbeing Support

Prehabilitation Goals (patient-centred)

Patient Concerns & Expectations

Patient's Main Concerns

Patient's Goals for Surgery

Consent & Information Provided

Surgical risks explained Prehabilitation programme explained MDT team introduced Written information provided

Clinical Summary & Recommendations

Summary

Recommendations to Surgeon

Next Review Date

Sign-Off

Assessing Practitioner

HPCSA Number

Date of Assessment

Report Status

Additional Notes / Addendum

SOAR Health Centre — Pre-Operative Assessment Report

Not assessed