Preoperative History and Physical Examination

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					                               Preoperative History and Physical Examination


Name:                                              Examination Date:
Date of Surgery:                                   Surgeon:
Procedure:


History of Illness:


Drug Allergies:


Medications:


Past Medical History:

               Cardiac History:    Yes No
                      Diabetes:    Yes No
                   Steroid Use:    Yes No
                   Diuretic Use:   Yes No
             Clotting Disorder:    Yes No
                      Smoking:     Yes No
                        Alcohol:   #/wk ________
                      Pregnant:    Yes No (LNMP ________) Menopausal
   Prior Anesthesia Problem:       Yes No
                  Prior Surgery:



Family History:


Review of Systems:




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                          Preoperative History and Physical Examination


Name:

Height:                                          Weight:
BP:                     HR:                      Resp:                   Temp:
General Appearance:

HEENT:

Neck:

Chest:

Breast:

Heart:

Abdomen:

GU:

Extremities:

Neuro/Mental Status:

Assessment:



Plan:




William C. Miller, MD    C. Anthony Kurian, MD             Forest Hills Medical Associates
                                                           6620 Clough Pike
                                                           Cincinnati, OH 45244
Signature: _____________________________________           231-9010


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