PDF HISTORY? STABLE? NO NO YES YES
Patient Name
310 East 14th Street New York, NY 10003-4297
ADULT PRE-OPERATIVE MEDICAL EVALUATION
Tel: (212) 979-4306 Fax: (866) 333-0174
Date of Birth
Surgical Procedure/ Chief Complaint/ Details Present Illness
Surgery Date Surgeon
Anesthesia Type
*NUR PREOPMEDEV*
Allergy/ Medication Sensitivity:
NUR PREOPMEDEV
CONDITION
1 Coronary Artery Disease 2 Hypertension
3 Congestive Heart Failure
4 Cardiac Arrhythmia
H 5 VaIvular Heart Disease
6 Pulmonary Disease
I 7 Diabetes Mellitus
8 Bleeding Diathesis
S 9 Renal Disease
10 Hepatic Disease
T 11 Other Medical Condition(s)
Surgical History
0
HISTORY? STABLE? NO YES YES NO
INDICATE CONDITION NUMBER # - Provide details and general review of systems
Relevant Family/ Social History
R Last Menses
(If Applicable)
Y
M E
D
ID
CO
A&S
TE
IS
0
N
S
P B.P.
H Y S PULSE
HEART LUNGS
I
C OTHER PERTINENT FINDINGS:
A
L
NORMAL
Tobacco Use
ABNORMAL
ETOH Use
Drug Use
DESCRIBE ABNORMAL FINDINGS
D LABORATORY, EKG, and X-Ray Evaluations See NYEE website (Admitting Forms - item 1. b.) for minimum requirements. Supply other pertinent results A deemed necessary. Send reports and mounted interpreted EKG's with this form. Please comment here on abnormal results.
T
A
C Do you wish to make any peri-operative management recommendations?
No
Yes
L STATEMENT OF CLEARANCE: ''There are no medical contraindications for the proposed procedure.''
E
A Examiner's Name (Printed)
License #
Date
Time
R A Examiner's Address
Telephone #
N C Examiner's Signature
Date
Time
E I have reviewed the above documented history and physical examination and have reevaluated and reexamined the patient. Except for any changes or
*SURGEON'S findings listed below, I certify that the patient's history, physical findings and condition are materially unchanged: REVIEW ____________________________________________________________________________________________________________________________
Surgeon Signature
Print Name
Date
Time
nur.008 FormFast 08/31/2018 MED - 1/98 904028
................
................
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