PREOPERATIVE EVALUATION FORM

Luis Cuadros MD

8232 Louisiana NE, Suite A

Albuquerque, New Mexico 87113

tel 505-243-7670 fax 505-242-0510

info@cuadrosmd.com



Last Name , First Name

 

 

M.I.

 

Age

 

Sex

□ M □ F


8 digit CSN no.

 

 

 

 

 

 

 

 

 

admission date

 

9 digit Med rec no.

 

 

 

 

 

 

 

 

 

 

 

date of birth

 

SSN:

 

admitting diagnosis

 

procedure(s) planned

 

location

    □ Pres Main Pres Day Kaseman

status

    □ Ambulatory outpatient Bedded outpatient Inpatient

pay source / insurance

    □ cosmetic self-pay PHP Pres Salud Other:

primary care physician

 

consultants

 



Phone contact:

Home

 

Work

 

Cell

 

Contact name if minor:

 

relationship

 

Emergency contact:

 

phone

 

Discharge support:

 

phone

 

City of Residence

 

staying at

 

language

 

interpreter

 

NPO

per guidelines

arrival time

 



Completed by

 

Date

 


Notes

 



Medications – prescription and OTC – (•) if instructed to take in AM of surgery with sip of water

Name/dose

route

frequency

comment

(•)

1

 

 

 

 

 

2

 

 

 

 

 

3

 

 

 

 

 

4

 

 

 

 

 

5

 

 

 

 

 

6

 

 

 

 

 

7

 

 

 

 

 

8

 

 

 

 

 

 

Previous Surgery and Hospitalizations (dates) or attach list

1

 

2

 

3

 

4

 

5

 

6

 

 

Current Active Medical Problems:

1

 

2

 

3

 

4

 

5

 

6

 

 

Allergies or Sensitivities to medications, latex, topicals, OTC, etc.

 

no

yes

describe reaction

Medications

 

 

 

1

 

 

 

 

2

 

 

 

 

3

 

 

 

 

4

 

 

 

 

latex

 

 

 

topicals

 

 

 

tape

 

 

 

food

 

 

 

OTC

 

 

 

environmental

 

 

 

other

 

 

 

 


Pertinent Past Medical History and Review of Systems

 

yes

no

explain

 

 

yes

no

explain

Anemia

 

 

 

 

Heart disease, MI

 

 

 

Anesthesia problems

 

 

 

 

Hormone replacement

 

 

 

Arrhythmia, irreg heart beat

 

 

 

 

Hypertension

 

 

 

Arthritis

 

 

 

 

Jehovah Witness

 

 

 

Asthma

 

 

 

 

Last menstrual period

 

 

 

Bleeding problems

 

 

 

 

Pneumonia

 

 

 

Cancer

 

 

 

 

Psych Depression Anxiety

 

 

 

Circulation problems

 

 

 

 

Pulmonary embolus

 

 

 

Dentures/loose teeth

 

 

 

 

Sleep apnea or snoring

 

 

 

Diabetes

 

 

 

 

Thyroid

 

 

 

DVT - blood clots

 

 

 

 

Transfusions

 

 

 

GE Reflux

 

 

 

 

Wound infections

 

 

 

 

MH malignant hyperthermia

 

 

self or family, explain:

Exposure to infection

 

 

TB HIV Hepatitis STD's MRSA Other:

Other/Explain

 

 

Social History

occupation

 

marital status

 

children

 

lives with

 

lives where

 

language/interpreter

 

 

Habits

smoking

 how much When stopped

ETOH

 

 

Family History: ASK: birth defects, heart disease, anesthesia, cancer, malignant hyperthermia

□ No □ Yes:

 

Physical Examination:

BP

Pulse

Temp

Height

Weight Kg

Weight lbs             

Lungs:

Heart:

Other:

VS, HEENT, NECK, LUNGS, HEART, ABD, EXT, GYN, GU, NEURO

 

 

Tests

Date

Result

Comments

Labs

 

Hb Hct K+

 

EKG

 

 

 

medical

clearance

 

 

 

xrays/other