Pre-Op History And Physical Form - Montgomery Surgery Center Page 2
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1
2Montgomery 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 _________________________________________________________________________________________________
□
□
□
□
□
□
□
WNL
HEENT
PERRLA
EOMI
No Lymphadenopathy
No JVD
O/P MNL
Thyroid WNL
Abnormal:
___________________________________________________________________________________________________________________
□
□
□
Cardiovascular
RRR S1S2
S3
S4
Abnormal:
______________________________________________________________________________________________________________________________
Pulmonary
□
Lungs CTA B/L
Abnormal:
_________________________________________________________________________________________________________________
□
□
GI
Abd Benign- Normoactive BS
No Hepatosplenomegaly
Abnormal:
___________________________________________________________________________________________________________________________
□
□
□
Extremities
No Clubbing
No Cyanosis
No Edema
Abnormal:
___________________________________________________________________________________________________________________________
Musculoskeletal
□
NML Muscle Tone
□
NML Strength
Abnormal:
___________________________________________________________________________________________________________________________
Neurological
□
CN II-XII
□
DTR intact and equal bilaterally
□
NML Mental Status
Abnormal:
___________________________________________________________________________________________________________________________
Genitalla/Rectum
□
Deferred
□
No masses
□
Heme negative
Abnormal:
___________________________________________________________________________________________________________________________
□
Assessment:
medical conditions optimized, further testing not recommend, patient may proceed directly to surgery
□
Further evaluation needed as follows:________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Comments: _________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
____________________________________________________________________________
______________
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.
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