Pre-Op History And Physical Form - Montgomery Surgery Center
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1
2Montgomery Surgery Center
46 W. Gude Dr.
Rockville, Md. 20850
(P) 301-424-6901
(F) 301-309-6863
Pre-op History and Physical Form
To Be Completed By PHYSICIAN - PA or Nurse Practitioner Requires Physician Signature
Patient Name: ___________________________________________________ DOB: ______________
Date: _____________________
Diagnosis: ______________________________________________________ Proposed Surgical Procedure: ________________________
Surgeon: ________________________________________________________ Date of Surgery: ___________________________________
Medical History/ Review of Systems - Check Box if applicable
none
Neuromuscular
none
GI Endocrine
none
Cardiovascular
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none
Pulmonary
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□ Hypertension
Asthma
TIA or stroke
Hiatal Hernia
□
□
□
Angina/chest pain
COPD/Emphysema
Seizures
Reflux
□
□
□
□
MI / CAD
Smoking History
Cerebrovascular Disease
Hepatitis Type ____
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□
□
□
□
CHF
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SOB
□
Dementia
□
Cirrhosis
□
Arrythmia/ palpitations
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Sleep Apnea
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Osteoarthritis
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Thyroid Disease
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Pacemaker/ AICD
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CPAP
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Rheumatoid Arthritis
□
Recent Steroid Use
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Valvular Disease
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Cough
□
Psychiatric Disorder
□
Obesity
CABG/ Cardiac Surgery
Wheezing
Neuromuscular Disease
Diabetes __І _____∏
□
□
□
Coronary Stent
PND/ Orthopnea
Syncope
Other ________________
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□
□
□
Poor Exercise Tolerance
URI
Other ________________
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PVD
Other _____________
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□
□
Other _______________
Hematologic
□
none
GYN/GU Renal
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none
Anesthesia Airway
□
none
Pediatrics
□
normal
□
Anemia
□
Pregnant
□
Family Hx Anesthesia problems
□
Recent URI/ Illness
□
Sickle Cell Disease / Trait
□
LMP _________
□
Previous Anesthesia Complications
□
Prematurity
Bleeding Disorder
Kidney Disease
Congenital Anomaly
□
□
□
Cancer
UTI
Apnea
□
□
□
Chemotherapy
Other ________
Other ______________
□
□
□
Other ___________
□
Comments on Positives or Symptoms/Conditions Not Listed:___________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Allergies
Current Medications
Medication
Dosage
Frequency
Medication
Dosage
Frequency
Past Surgical History
Date
Surgery
Hospital Name
Complications
Social History: Smoking______________________ Alcohol___________________________ Drugs________________________________
Family History: □non-contributory____________________________________________________________________________________
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