GLP-1 Pre-Op Checklist: A Printable Medication Note for Surgery

A GLP-1 pre-op checklist is a single page that tells your surgical and anesthesia team exactly what GLP-1 medicine you take, when your last dose was, whether anything changed recently and how your stomach has been. Those are the facts current guidance uses to decide whether you need a special plan. Below is a free fill-in template you can copy, print or paste into your phone notes.

The template records facts. It doesn't tell you whether to hold or keep taking your medicine. That decision belongs to your care team. (Why the team cares at all is covered in what your anesthesia team needs to know.)

Why a written pre-op note beats remembering

A typical pre-op week includes a call from the surgeon's office, a call or visit from pre-admission testing, maybe a message from anesthesia, and then a nurse on the morning itself asking the same questions again. Weekly injections are easy to forget in that rush. You don't take them every day, and they live in the fridge, not the pill organizer.

GLP-1 labels now include a warning that these medicines delay stomach emptying, and that rare cases of pulmonary aspiration have been reported under general anesthesia or deep sedation. The labels tell prescribers to have patients tell their healthcare providers before any planned surgery or procedure. The 2024 multi-society guidance (ASA, AGA, ASMBS, ISPCOP, SAGES) then sorts people by risk using four things: where you are in dose escalation, your dose, your current GI symptoms, and other conditions that slow the stomach. The template asks for exactly those.

How to use this template

1. Copy it into a document, a notes app or onto paper.
2. Fill in Parts 1–4 the day your surgery or procedure is booked.
3. Update Part 2 if you take another dose before the procedure.
4. Fill in Part 5 when the team gives you the plan, using their words.
5. Bring it (on paper or on your phone) to every pre-op visit and on the day.

The printable GLP-1 pre-op medication note

Part 1: About me and the procedure

Item	Fill in
Name / date of birth
Procedure and date
Surgeon or proceduralist
Type of anesthesia, if known (general / sedation / local)
Prescriber of my GLP-1 (name, phone)
Pharmacy (name, phone)

Part 2: My GLP-1 medicine

Item	Fill in
Brand name, exactly as on the label (e.g., Wegovy, Ozempic, Mounjaro, Zepbound, Rybelsus, Foundayo, Saxenda)
Active ingredient (semaglutide, tirzepatide, liraglutide, orforglipron…)
Form: weekly injection / daily injection / daily tablet
Current strength (from the pharmacy label)
Brand-name or compounded? (if compounded: pharmacy name and concentration on the vial)
Why I take it (diabetes, weight management, sleep apnea, heart risk…)
My usual dose day / time
Date and time of my most recent dose
Date I started this medicine
Date of my last strength increase
Any missed doses or breaks in the past month?

Part 3: How my stomach has been (past 2 weeks)

Tick what applies and add a word or two:

Symptom	Yes / No	When, how often
Nausea
Vomiting
Reflux or heartburn
Bloating or abdominal pain
Constipation
Feeling full for hours after a small meal
Trouble keeping food or fluids down

The 2025 SPAQI consensus treats severe nausea, vomiting or inability to tolerate food as "significant" symptoms that should be dealt with before elective anesthesia. It does not count ordinary fullness or early satiety as significant. Write down what you actually feel and let the team judge.

Part 4: Everything else the team needs

Item	Fill in
Other diabetes medicines (insulin, sulfonylureas, SGLT2 inhibitors, metformin…), with doses
Blood thinners or antiplatelet medicines
All other prescriptions
Over-the-counter medicines, vitamins, supplements
Allergies and what happens
Conditions that slow the stomach (gastroparesis, Parkinson's disease, previous stomach surgery)
Any past problems with anesthesia (me or close family)

Part 5: The plan my team gave me (write it word for word)

Item	Fill in
Who gave the instructions (name, role, date)
What to do with my GLP-1 before the procedure
What to eat and drink, and from when
What to do with my other diabetes medicines
Who to call if I get nausea or vomiting beforehand
When and how to restart afterwards
Does my prescriber agree? (yes / waiting / not asked)

Tips for filling it in accurately

• Read the label, not your memory. "The blue one, the middle dose" doesn't help anyone. The pharmacy label has the product name, strength and the date it was filled.
• Be specific about compounded products. Compounded semaglutide or tirzepatide isn't the same thing as an FDA-approved brand. Write down the pharmacy and the concentration printed on the vial. Our post on compounded GLP-1 red flags explains why this matters.
• Don't record a self-made change as if it were the plan. If you decided on your own to skip a dose, write "I skipped my dose on [date]" in Part 2. Don't put it in Part 5.
• Update the "most recent dose" line. If your procedure is a week away, you may take another dose before then, unless the team tells you otherwise.
• One note per procedure. A colonoscopy or endoscopy may come with different instructions than a knee replacement.

If you log your shots in GLPily, the shot log already has most of Part 2: dose dates, strength changes and missed weeks. Your symptom entries can fill in Part 3.

What this template is not

It doesn't tell you whether to stop your medicine, how long to fast or how to adjust insulin. Guidance on those questions changed between 2023 and 2025, and hospitals still use their own protocols. The template gives the team what it needs and gives you a record of what they decided.

For non-surgical emergencies, keep a shorter version in your wallet. See our urgent care medication list.

Common questions

Should I bring this to a dental sedation or a minor procedure too?

Yes, if sedation is involved. The FDA label warning covers general anesthesia and deep sedation, so any team putting you under should get the same facts.

What if I don't know the exact date of my last dose?

Check your pharmacy fill history, your pen's dose counter or your shot log. If you still don't know, write "unsure, approximately [date]." An honest "unsure" is better than a precise guess.

Can I just show my pharmacy app instead?

It helps, but pharmacy apps show what was dispensed, not when you took it or how your stomach has been. Parts 2, 3 and 5 are the bits only you can provide.

Who fills in Part 5 if my surgeon and prescriber disagree?

Write down both instructions and tell each team what the other said. Ask them to agree on one plan before the procedure. Don't pick one yourself.