Preoperative Medical Assessment - New York Eye & Ear

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Patient Name:

Date of Birth:

PRE - OPERATIVE MEDICAL

ASSESSMENT (ADULT)

Admission Date:

Admitting Physician (FULL NAME W/MIDDLE INITIAL):

Preferred

Language

English

Chinese

Mandarin

Spanish

Russian

Other:

Cantonese

Planned Surgical Procedure:

Date Planned Surgery:

Hospital/Location of Surgery:

Attending Surgeon:

History of Present Illness:

All relevant preoperative PMH listed below was reviewed and found to be negative unless specified below.

Past Medical History

Yes

Date

Yes

Cardiac History

CKD Stage _______ Dialysis

Pulmonary Hypertension (latest PAP ______)

TIA/CVA/hemiplegia/hemparesis/ residual deficit

Congenital heart disease

DVT/PE

MI (Yes/No, 4 or

Unable to assess

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