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IDENTIFICATION CARD
MEDICAL HISTORY
PREOPERATIVE PREPARATION
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ELECTROCARDIOGRAMS
ANESTHESIA
TRANSQUIRURGICO/TRANSSURGICAL
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IDENTIFICATION CARD
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Name
*
First
Last
ID
*
NUMBER
*
DAY SURGERY NUMBER
*
DATE
*
ROOM
*
SURGERY PERFORMED
*
SELECT ONE
SLEEVE
ROUX-EN-Y GASTRIC BYPASS
OAGB
SADIS-SD
ROUX-EN-Y GASTRIC BYPASS WITH FUNDOPLICATION
ENDOSCOPIC SLEEVE
SLEEVE REVISION
ROUX-ENY GASTRIC BYPASS REVISION
OAGB REVISION
SADIS REVISION
BAND TO SLEEVE CONVERSION
BAND TO ROUX-EN-Y GASTRIC BYPASS CONVERSION
BAND TO OAGB CONVERSION
BAND TO SADIS/SD CONVERSION
BAND TO ENDOSCOPIC GASTRIC SLEEVE
BAND TO ROUX-EN-Y WITH FUNDOPLICATION CONVERSION
SLEEVE TO ROUX-EN-Y GASTRIC BYPASS CONVERSION
SLEEVE TO OAGB CONVERSION
SLEEVE TO SADIS CONVERSION
SLEEVE TO ROUX-EN-Y GASTRIC BYPASS CONVERSION
SLEEVE TO OAGB CONVERSION
SLEEVE TO SADIS CONVERSION
SLEEVE TO ROUX-EN-Y GASTRIC BYPASS CONVERSION
SLEEVE TO ROUX-EN-Y GASTRIC BYPASS WITH FUDOPLICATION
OAGB TO ROUX-EN-Y GASTRIC BYPASS
OAGB TO SADI CONVERSION
ROUX-EN-Y GASTRIC BYPASS TO SADI CONVERSION
OAGB REVERSAL
ROUX-EN-Y GASTRIC BYPASS REVERSAL
SADI REVERSAL
ROBOTIC SLEEVE
ROBOTIC ROUX-EN-Y GASTRIC BYPASS
ROBOTIC OAGB
ROBOTIC SADIS/SD
ROBOTIC SLEEVE REVISION
ROBOTIC ROUX-EN-Y GASTRIC BYPASS REVISION
ROBOTIC OAGB REVISION
ROBOTIC SADIS REVISION
ROBOTIC BAND TO SLEEVE CONVERSION
ROBOTIC BAND TO OAGB CONVERSION
ROBOTIC BAND TO ROUX-EN-Y GASTRIC BYPASS CONVERSION
ROBOTIC BAND TO SADIS/SD CONVERSION
ROBOTIC SLEEVE TO OAGB CONVERSION
ROBOTIC SLEEVE TO ROUX-EN-Y GASTRIC BYPASS CONVERSION
ROBOTIC SLEEVE TO SADIS CONVERSION
ROBOTIC OAGB TO ROUX-EN-Y GASTRIC BYPASS CONVERSION
ROBOTIC OAGB TO SADI CONVERSION
ROBOTIC ROUX-EN-Y TO SADIS CONVERSION
ROBOTIC OAGB REVERSAL
ROBOTIC ROUX-EN-Y GASTRIC BYPASS REVERSAL
ROBOTIC SADIS REVERSAL
OTHER
WHICH ONE ?
*
ADDITIONAL SURGERY?
*
YES
NO
WHICH ONE ?
*
OPERATING ROOM NUMBER
*
OBSERVATIONS
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IDENTIFICATION CARD
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