Montgomery Surgery Center
46 W. Gude Dr.
Rockville, Md. 20850
(P) 301-424-6901
(F) 301-309-6863
Patient Name: ___________________________________
Pre-operative Physical Examination Form – PAGE 2
PHYSCIAL EXAM
Sex
Race
Age
Height
Weight
BP
Pulse
Resp
Temp
General Appearance _________________________________________________________________________________________________
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WNL
HEENT
PERRLA
EOMI
No Lymphadenopathy
No JVD
O/P MNL
Thyroid WNL
Abnormal:
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Cardiovascular
RRR S1S2
S3
S4
Abnormal:
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Pulmonary
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Lungs CTA B/L
Abnormal:
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GI
Abd Benign- Normoactive BS
No Hepatosplenomegaly
Abnormal:
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Extremities
No Clubbing
No Cyanosis
No Edema
Abnormal:
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Musculoskeletal
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NML Muscle Tone
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NML Strength
Abnormal:
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Neurological
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CN II-XII
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DTR intact and equal bilaterally
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NML Mental Status
Abnormal:
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Genitalla/Rectum
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Deferred
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No masses
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Heme negative
Abnormal:
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Assessment:
medical conditions optimized, further testing not recommend, patient may proceed directly to surgery
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Further evaluation needed as follows:________________________________________________________________________________________
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Comments: _________________________________________________________________________________________________________________
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MD/Name (Print)____________________________________________________________________________ Date ______________________________
Physician Signature ________________________________________________________________________ Phone Number (
)_________________
Private Line ( ____)_________________
PLEASE FAX FORMS IMMEDIATELY UPON COMPLETION TO 301-309-6863. FAILURE TO
RECEIVE FORMS AT LEAST ONE WEEK PRIOR TO SURGICAL DATE MAY RESULT IN
CANCELLATION OF THE PROCEDURE. THANK YOU.