History And Physical Evaluation Form - American Surgery Center
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1
2History and Physical
Evaluation Form
Please fax completed form to 302.777.2111
Patient Name________________________________________________________ Age_______ Gender______________
Pre-Op Diagnosis_______________________________________ Proposed Surgery______________________________
Allergies/Reactions_______________________ Latex Allergy____________ HABITS (Smoker, ETOH)_____________
Herbal Supplements__________________________________ (OTHER)_______________________________________
Medications/Dosages________________________________________________________________________________
Indications for surgery (how activities of daily living are affected?): ___________________________________________
This section to be completed by the examining surgeon or physician:
PAST MEDICAL/SURGICAL HISTORY
□ ICD
□ Pacemaker
□ HTN
□ CAD
□ CHF
□ Arrhythmia
□ Aortic Stenosis
□ Sleep Apnea
□ Murmur
□ Hyperlipidemia
□ DM Type-1/2
□ Dementia
□ COPD
□ Asthma
□ Liver Disease
□ CVAITIA
□ Abnormal Bleeding/Bruising
□ DVT
□ GERD
□ Hypothyroid
□ Seizure Disorder
□ ESRD
□ Dialysis
□ Transplant
□ Prior Anesthetic Complications
Comments ________________________________________________________________________________________
_________________________________________________________________________________________________
PHYSICAL EXAMINATION
HT: _______ WT: _______ B/P: _______ P: _______
For straight local anesthesia physician must assign ASA class ______________
GENERAL APPEARANCE: __________________________________________________________________________
IF NO SIGNIFICANT FINDINGS, CHECK BOX: DESCRIBE ABNORMAL FINDINGS
NON-CONTRIBUTORY
□ HEART
___________________________________________________________
□ LUNGS
___________________________________________________________
□
□ HEENT
___________________________________________________________
□
□ GI/AB
___________________________________________________________
□
□ GU
___________________________________________________________
□
□ BACK
___________________________________________________________
□
□ EXT
___________________________________________________________
□
□ NEURO
___________________________________________________________
FOR PEDIATRIC PATIENTS
(6 months - 18 years) having surgery in Delaware Surgery Centers: Check appropriate box.
I have contacted the primary care provider for this patient, Dr.________________________ who agrees that it
is appropriate to do the surgery in an ambulato,y surgery center versus a hospital.
As the primary care provider for this patient, I agree that it is appropriate for this procedure to be done in a
surgery center versus a hospital.
DATA (LABS, ECG, ETC. - PLEASE REFER TO BACK PAGE)
IMPRESSION (PLEASE SIGN BELOW)
After examining the patient and reviewing the preoperative data, l find this patient to be medically stable for the proposed
surgery and appropriate for care in an ambulatory center versus a hospital.
Signature _____________________________
Date ____________
.
M.D., D.O
Printed Name ____________________________ Phone ________________
DAY OF SURGERY PRE OP REVIEW (Required for straight local
anesthesia cases only) - I have reviewed this History and Physical and
PATIENT LABEL
examined the patient for changes since its performance. Based upon my
assessment no changes have occurred and the patient may proceed with the
planned procedure.
Surgeon’s Signature ___________________________Date ___________
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