Physician Signature: Date: Time

Referring Physician: ______Phone Number: ______

Chief Complaint: ______

______

History of present illness: ______

______

Past Medical History

Allergies: £ NKDA or £ Other (specify): ______

Medication: £ None or £ List: ______

______

Surgeries: ______

Previous Anesthesia Type: £ Local £ General £ Sedation £ Complications: ______

Family History
Co-Morbidities: / MI £ ______
CVA £ ______
£ Hypertension / £ Renal Disease / Malignant Hyperthermia £ ______
£ Heart Disease / £ Neurologic / Problem Anesthesia £ ______
£ Diabetes / £ Liver Disease / ______
£ Pulmonary Disease / £ GI (Bleeding) / ______
Social History
Comments: ______/ Occupation: ______
______/ Tobacco: ______
______/ Alcohol: ______
Other Drugs: ______
REVIEW OF SYSTEMS Please check any system with abnormality(ies)
Comments:
£ Vascular ______/ £ Exercise Tolerance ______
£ HEENT ______/ £ GU ______
£ Cardiac ______/ £ Musculoskeletal ______
£ Pulmonary ______/ £ Neuro ______
£ GI ______/ £ Hematology ______
Vital Signs / BP / P / R / Temp / WT / HT
(current)
(Update – if required)

Physical Exam

HEENT: ______/ GI/Abdomen: ______
Neck: ______/ Rectal: ______
C/V: ______
Pulmonary: ______
Breast: ______/ Neurologic:______
Skin:______

Diagnosis/Impression: ______

______

Plan: ______

______

Name (please print) ______Signature ______

Date ______Time ______Beeper Number ______

Attending Physician:

£ Patient was seen, examined, and discussed with the house staff and I agree with the findings and plan. My impression and plan are documented in the house staff’s

notes which I supervised and corrected.

£ Patient was discussed with the house staff and I agree with the findings and plan. My impression and plan are documented in the house staff’s notes which I

supervised and corrected.

Attending Signature ______Date ______Time ______

Update: (If Required, include Vitals, see above) ______
______
Signature ______Date ______Time ______
Beeper Number ______

Regional One Health Surgery Center

Preoperative History & Physical Affix Patient Label

Form No.OSC.076 (Rev. 11/13)

Original Copy (chart) Yellow Copy (Provider)