History & Physical (Short Form)
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1450 Stanyan Street • San Francisco, CA 94117-1079
HISTORY & PHYSICAL (SHORT FORM)
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PROPOSED SURGERY/PROCEDURE:
SURGICAL/PROCEDURAL INDICATIONS AND PRESENT ILLNESS:
DIAGNOSIS:
RELEVANT PAST HISTORY:
Non-contributory
ALLERGIES:
NONE
CURRENT DRUGS:
Review of Systems (Recent History)
Neg
Relevant History
Neg
Relevant History
General:
GU:
EENT:
MUSCULOSKELETAL:
RESP:
NEURO:
CV:
PSYCH:
GI:
OTHER:
Blood Pressure
Temp
Pulse
Resp
If not performed by physician:
Date:
Time:
Signature and Title
Physical Exam
Within Normal Limits Signifi cant Physical Findings:
Heart
Lungs
Airway
Other:
Examination relative to Surgery / Procedure:
Reviewed and verifi ed history as reported above
Physician’s Signature ______________________________________ Date ________________ Time _______________
Form can be used ONLY for Ambulatory, non-impatient, or Other Procedures requiring and H&P or a 7 day H&P update.
7430-001 (06/21/11)
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