Pre-Procedure History and Physical
Patient Name
DOB
-
Month
-
Day
Year
Date
Diagnosis/History of Present Illness
Past Medical History
Prior Surgery
Problems with Surgery/Anesthesia
Problems with Surgery/Anesthesia
None
Current Medications and Dosages (include Herbals, Over the Counter):
Rows
-
Allergies
None Known
Allergies
System Review: (Check when Reviewed; Comment if Positive)
Head/Neck
System Review: (Check when Reviewed; Comment if Positive)
Integumentary
System Review: (Check when Reviewed; Comment if Positive)
Cardiac
System Review: (Check when Reviewed; Comment if Positive)
Neurological
System Review: (Check when Reviewed; Comment if Positive)
Pulmonary
System Review: (Check when Reviewed; Comment if Positive)
Psychiatric
System Review: (Check when Reviewed; Comment if Positive)
Gastrointestinal
System Review: (Check when Reviewed; Comment if Positive)
Endocrine
System Review: (Check when Reviewed; Comment if Positive)
Genitourinary
System Review: (Check when Reviewed; Comment if Positive)
Musculoskeletal
System Review: (Check when Reviewed; Comment if Positive)
Hematologic
System Review: (Check when Reviewed; Comment if Positive)
Immunology
Head/Neck
Integumentary
Cardiac
Neurological
Pulmonary
Psychiatric
Gastrointestinal
Endocrine
Genitourinary
Musculoskeletal
Hematologic
Immunology
None (Check and Comment below if yes)
Cardiovascular History:
Hypertension
Angina
Pre-Procedure History and Physical
MI (Dates)
CABG
Valve Disease
Valve Disease
Valve Disease
Angioplasty (Dates)
/
Month
/
Day
Year
Date
Angioplasty (Dates)
/
Month
/
Day
Year
Date
Angioplasty (Dates)
COPD
Angioplasty (Dates)
CPAP
Angioplasty (Dates)
Steroids
Arrhythmia
Rows
-
Hypertension
None (Check and Comment below if yes)
Arrhythmia
None (Check and Comment below if yes)
Pulmonary History:
None (Check and Comment below if yes)
None (Check and Comment below if yes)
Sleep Apnea
None (Check and Comment below if yes)
Asthma
None (Check and Comment below if yes)
Other
Other
None (Check and Comment below if yes)
H/O Substance Abuse
Sleep Apnea
CPAP
CPAP
Asthma
Social History
Smoking Packs/Years
Social History
ETOH:
Smoking Packs/Years
No
Current Use?
Yes
Family History
Family History
Non-contributory
Non-contributory
BP
Pulse
RR
Wt
Ht
(Check when reviewed: describe if abnormal)
General
(Check when reviewed: describe if abnormal)
HEENT
(Check when reviewed: describe if abnormal)
Pulmonary
(Check when reviewed: describe if abnormal)
Cardiac
(Check when reviewed: describe if abnormal)
Gastrointestinal
(Check when reviewed: describe if abnormal)
Musculoskeletal
(Check when reviewed: describe if abnormal)
Skin
(Check when reviewed: describe if abnormal)
Neurological
(Check when reviewed: describe if abnormal)
Psychiatric
(Check when reviewed: describe if abnormal)
Other
Other
General
HEENT
Pulmonary
Cardiac
Musculoskeletal
Musculoskeletal
Skin
Neurological
Psychiatric
Labs
Imaging Studies
Impression
Plan
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