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PLEASE CONTINUE ON REVERSE SIDE
PHYSICAL EXAMINATION
(To be used only if planned admission is less than 48 hours)CHIEF COMPLAINT___________________________________________________________________________________________________________________________________________________________________________________________________HISTORY OF PRESENT ILLNESS__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PAST MEDICAL HISTORY___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Past Surgeries ________________________________________________________________________________________Relevant Family History _____________________________________________________________________________________________________________________________________________________________________________Allergies __________________________________________________________________ NKDA Latex AllergyMedications _______________________________________________________________________________________________________________________________________________________________________________________Social History Tobacco packs/year _________________ ETOH _____________ Street Drugs ___________________
Vital Signs: BP __________ TEMP __________ PULSE __________ RESP __________
NORMAL ABNORMAL IF ABNORMAL, SPECIFY FINDINGS
Skin
Head / Ears / Nose / Throat
Heart
Lungs
Abdomen
Extremities
GU
Form No. 7031-0102 Org. (4/07) Rev. (6/10)
5900 WEST OLYMPIC BLVD.LOS ANGELES, CA 90036-4671
PATIENT
ID
AMBULATORY SURGERY / SHORT STAY
HISTORY AND PHYSICAL
REVIEW OF SYSTEMS
Hypertension Coronary Artery Disease
Angina MI CABG Stable
Dysrrhythmia CHF Valvular Dis
Rheumatic Heart Dis Other: _____________________ Peripheral Vascular Disease Source of Infection
Skin Indwelling Catheter Prosthesis Other: ________________
CARDIOVASCULARAsthma
Last Attack: ______________ Chronic Bronchitis Pneumonia COPD URI Tuberculosis Sleep Apnea CPAP Home O2 Other _____________________
RESPIRATORY
Osteoarthritis Rheumatoid Arthritis Spinal disc disease Trauma Other: ____________________
SKELETAL
Obesity Peptic Ulcer Dis Gastro Esophageal
Reflux Disease Hiatal Hernia Jaundice Hepatitis A, B, C Other: ____________________
GI
Seizure Stroke/TIA Neuropathy Neuro Musc. Dis Other: ____________________
NEUROLOGIC
Renal Insufficiency Endstage Renal Disease Dialysis UTI Urinary Retention BPH Other: ____________________
GU
Diabetes Type 1 Type 2 Thyroid Post Menopausal Other: ____________________
ENDOCRINE
Anemia Coagulopathy Other: ____________________ Prior Transfusion
HEMATOLOGIC
DISCHARGE PROGRESS NOTE
SUMMARY OF FINDINGS / FINAL DIAGNOSES
PLAN OF CARE
PERTINENT / ABNORMAL LAB, XRAY, EKG RESULTS
Discharge Date:Discharge Diagnoses:
Medication(s):
Diet:
Limitation of Activity:
Follow-Up:
Preop Interventions:
PHYSICIAN NAME (Print Legibly) ID# DATE SIGNEDPHYSICIAN SIGNATURE / MD
ARE THE PATIENTS MEDICAL CONDITIONS OPTIMIZED FOR SURGERY? YES NO NAPhysician Name (Print Legibly) ID# Date SignedPhysician Signature (MD)
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