Pre-Procedure History-Physical Examination Form
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2One Medical Center Drive, Lebanon, NH 03756
Pre-Procedure
History & Physical Examination
Addressograph
History & Physical completed by:
DHMC Staff Clinician
non-DHMC Staff Clinician
Chief Complaint/Diagnosis: _________________________________________________ Patient Age: ________ Code Status: ____________
Planned Procedure: _____________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
History of Present Illness: ___________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Medical/Surgical History: __________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Family History: _____________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Social History: ______________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Advanced Care Planning: ___________________________________________________________________________________________
(Write name of Durable Power of Attorney for Health Care or patient’s preferred medical decision-maker and relationship to patient.)
Advise patient that this named person would be asked to give medical consent on behalf of the patient to all medical treatments related
to the current Operative or Major Diagnostic or Therapeutic Procedure identified above. This named person’s authority will only exist
when the patient is unable to make his/her own medical decisions. Consideration should be given to postponing procedures under
circumstances in which no medical decision-maker is identified.
Drug/Latex Allergies/Sensitivities: _________________________________________________________________________________
______________________________________________________________________________________________________________________
ADR/Allergies List reviewed and updated in EMR
No known allergies
Current Medications: _______________________________________________________________________________________________
______________________________________________________________________________________________________________________
Medication list reviewed and updated in EMR
Review of Systems (ROS)
1) Pertinent positive findings: ____________________________________________________________________________________________
___________________________________________________________________________________________________________________
None
2) Remaining ROS (including: Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Neurological, Psychiatric,
Endocrine, EENT): ___________________________________________________________________________________________________
___________________________________________________________________________________________________________________
All negative
Page 1 of 2
Original to medical record – Tab 4: Inpatient Notes
Approved by OCA 8/08
RM/HIS 11-3-08
Rev. 10/08, 5-2-11
F-629
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