NAMA : _______________________________________________
CHECK LIST UMUR : ____________ L / P TGL : ____________
KESIAPAN ANESTESIA NO. RM/CM : _______________________________________________ JAM : _____ wita
DIAGNOSA PRE OP : _______________________________________________
JENIS OPERASI : TEHNIK ANESTESI : GA RA Spinal Epidural Kaudal CSE Blok Saraf Tepi