Pre-Surgical Clinic
History and Physical
Physician
Name:__________________________________________ Age:___________
Preoperative diagnosis:_____________________________________________
_______________________________________________________________
History:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Past Health:_______________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________
Current Medications:________________________________________________________________________________________
________________________________________________________________________________________________________
Allergies:_________________________________________________________________________________________________
Physical Examination Weight:______________________
Head and Neck:____________________________________________________________________________________________
________________________________________________________________________________________________________
Chest:___________________________________________________________________________________________________
Cardiovascular:____________________________________________________________________________________________
________________________________________________________________________________________________________
Abdomen:________________________________________________________________________________________________
________________________________________________________________________________________________________
Other Findings:____________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Date:___________________________ Signature:_________________________________________________________________
Consultant:
Diagnosis:________________________________________________________________________________________________
Proposed Procedure:________________________________________________________ Booked for (Date):_________________
Date:_______________________________________ Consultants
Signature:____________________________________________