Form C30869 - History & Physical Form (For Non-Heart Patients)

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C30869 (12/06)
HISTORY & PHYSICAL FORM (for non-heart patients)
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Patient Name ____________________________ DOB ______________
Minneapolis
St. Paul
Day Surgery – United
Minnetonka
2525 Chicago Avenue South
345 North Smith Avenue
310 North Smith Avenue
6050 Clearwater Drive
Minneapolis, MN 55404
St. Paul, MN 55102
St. Paul, MN 55102
Minnetonka, MN 55343
(612) 813-6191
(651) 220-6505
(651) 241-5540
(952) 930-8700
(612) 813-7704 Fax
(651) 220-7220 Fax
(651) 241-5067 Fax
(952) 930-8690 Fax
History and physical examinations must be completed no more than 7 days prior to admission or surgery, before any procedure and
not more than 24 hours post admission.
Primary Physician
Surgeon
date of examination
Time
date of Surgery
Procedure
Age
Wt.
kg Ht.
cm OFC
M N/A
(≤ 24 months of age)
BP
Pulse
Resp
T
Last Menstrual Period
M N/A
urine for pre-op pregnancy: (for 12 years and older or menstruating)
 negative  Positive
CHIeF COMPLAInT
HISTORY OF PReSenT ILLneSS
PAST MedICAL HISTORY
(pregnancy/perinatal history, medical, exposures, diet, development, transfusions, medications)
PAST SuRgICAL HISTORY
ALLeRgIeS
CuRRenT MedICATIOnS
nOTe: Please include all medications taken at home (vitamins, herbal remedies,
M No current medications
homeopathic therapies, and over-the-counter medications) in list of medications
M Information not available
nAMe
dOSe/ROuTe/FReQuenCY
START dATe
LAST TAKen
PuRPOSe
FAMILY HISTORY
(cardiac, cancer, respiratory, bleeding disorder, anesthetic reaction)
*HISTPHYS*

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