SHORT FORM HISTORY AND PHYSICAL - Anne Simon MD .com

[Pages:2]SHORT FORM HISTORY AND PHYSICAL

HISTORY:__________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

PAST HISTORY/FAMILY HISTORY: _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________

MEDICATION: _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

P.E. GENERAL:___________________________________ _________________________________________________ _________________________________________________ _________________________________________________

ALLERGIES:____________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

NECK:___________________________________________ _________________________________________________

HEENT:__________________________________________ _________________________________________________

V.S.

BP

P

R

T

_______________________________________________________

DX & TREATMENT PLAN:_______________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

RESP:___________________________________________ ________________________________________________

BREAST:________________________________________ ________________________________________________

HEART:_________________________________________ ________________________________________________

ABD:___________________________________________ ________________________________________________

RECTAL:________________________________________ _________________________________________________

THIS SECTION FOR ALL OUTPATIENTS INFORMED CONSENT

Prior to the following, the risk, benefits and alternatives were discussed with the patient, and/or family.

Procedure/Surgical Conscious Sedation

The Use of Blood Local Anesthesia

Patient remains an appropriate candidate to undergo procedure/surgery and sedation/local anesthesia.

PELVIC:_________________________________________ _________________________________________________

EXT:____________________________________________ _________________________________________________

Signature:________________________________________ Date:____________________________________________

NEURO:_________________________________________ _________________________________________________

NAME:____________________________________ D.O.B._____________________________________ SURGEON:_________________________________

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