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Medical Record No.
Physician Use:
Patient Name
EXAMINATION & MANAGEMENT
Birthdate
Physician
Circumcision Intake
Please align patient label to the right
De'id patient
MEDICAL CLEARANCE:
YES NO
Family: history bleeding absent
Height
History obtained from:
Mother _______
Boy:
heart disease absent
Weight
Father _______
GE reflux absent
>5lbs
Other _______
Vitamin K administered
<5lbs
Gestation age at birth
Systems: Constitutional
Abnormalities
Systems: Male Genitourinary
Abnormalities
• Vital signs:
• Testes:
___________________See Chart
_______________Normal
• General appearance:
• Inguinal/hernia:
___________________Normal
_______________Normal
• Epididymis:
_______________Normal
• Anus & perineum:
_______________Normal
May Be
Assessments for Suitability YES
NO
Comments
Unsuited for:
Penis Exam At Bedside
(may push penis base down to induce tumesence)
PENIS SHAFT
click site
length >3cm
Micropenis
of
straight (no chordee)
Chordee
penoscrotal
no torsion (<45° twist)
Penis Torsion
junction
GLANS CORONA
ridge evident
Guides pen mark
SKIN SURFACES
prepuce meatus circumferential
Glans tilt chordee
penopubic crease normal
Buried Penis
penoscrotal junction normal
Push down on
Scrotum Web
scrotum skin confined
PPJ to confirm
Buried Penis
penis/prepuce raphes straight
check for Glans tilt after retract prepuce
Penis Exam After Prepuce Retracted
glans size normal
urethra meatus on glans
glans not tilted
click one choice below
Penis suited to circumcise*
YES
*all clearances & assessments must be "YES"
NO
DIAGNOSIS:
Phimosis (Diagnosis Code: 605)
______________________________
Circumcision or ________________
Plan/Follow-up:
Signature
Date
99242-25
New Patient Consultation
E/M Code:
CEVL for Healthcare, Inc. |