Examination & Management - Circumcision Intake Page 2
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18Medical Record No.
Physician Use:
Patient Name
EXAMINATION & MANAGEMENT
Birthdate
Physician
about 10days after circumcision
Please align patient label to the right
History obtained from:
Height
Mother _______
Weight
Father _______
Other _______
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 Success
YES
NO
Unsuccessful
Comments
for:
CIRCUMCISION SITE
persistent foreskin
located below corona
circ site unenven
site parallels corona
SKIN SURFACES
penoscrotal junction normal
Buried Penis
GLANS
urethra meatus normal
Hypospadias
click one choice below
Circumcision is successful*
YES
*all assessments must be "YES"
NO
DIAGNOSIS:
Other diagnoses? ______________________
Phimosis (Diagnosis Code: 605)
Plan/Follow-up:
discharge
Other plans?
______________________
E/M Code:
Return Patient visit 99212
Dat
Signature: __________________________________________
CEVL for Healthcare, Inc. |
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