Last Name , First Name

 

 

M.I.

 

Age

 

 

9 digit PH Med rec no.

 

 

 

 

 

 

 

 

 

admission date

 

date of birth

 

SSN:

 

admitting diagnosis

 

procedure(s) planned

 

primary care physician

 

consultants

 



Allergies (medicine, latex, topicals, OTC) - describe

 

 

 


Medications (prescription and OTC)name, route, dose, frequency

 

 

 

 

 

 

 

 


Current Medical Problems

 

 

 

 

 


Previous Surgery and Hospital Admissions (dates)

 

 

 

 

 

 

 

 

 




Past Medical History and Review of Systems:

(ask and circle if positive, exclude current Medical problems)

anemia

pneumonia

DVT

pulmonary embolus

heart disease

hypertension

diabetes

asthma

arrythmia

circulation problems

cancer

bleeding problems

transfusions

Jehovah

psychiatric

anesthesthia problems

wound infections

LMP

 

 

Family History: relevant birth defects, heart disease, anesthesia, cancer

yes no

 

Social History / Habits

occupation

 

marital status

 

children

 

lives with

 

lives where

 

smoking, how much

 

ETOH

 

 

Physical Examination

BP

Pulse

 

 

Tests

Result

Laboratory

 

EKG

 

CXR

 

medical

clearance

 


NOTES: