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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