Physical Examination Sheet Form PDF Details

At the heart of patient care, especially before undergoing surgery, lies a crucial step: the meticulous completion of the Preoperative History & Physical Examination Form. Originating from Sinai Hospital's Rubin Institute for Advanced Orthopedics/International Center for Limb Lengthening, this document serves as a comprehensive tool to safely guide surgical plans and ensure personalized, patient-centered care. It meticulously records essential patient information, starting with basic demographics like name, date of birth, and diagnosis, to more intricate details regarding the proposed surgical procedure, surgeon identity, and specific surgery dates. Beyond the procedural specifics, the form delves into the patient's medical, surgical, social, and family history, alongside a thorough review of systems spanning from cardiovascular to neurological assessments. The form also includes a detailed current medications list and allergies, thus painting a holistic picture of the patient's health status. Critically, this form prompts a physical examination, tracking vital statistics and system-specific evaluations, which inform the final assessment of surgical risk and planning. It serves not just as routine paperwork but as a pivotal communication bridge between patients and their healthcare team, ensuring that every surgical decision is deeply informed by the patient's unique health landscape.

QuestionAnswer
Form NamePhysical Examination Sheet Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names2019 phyiscal form, 2019 kansas physical forms, lhsaa physical form 2019, memorial hospital prep op form

Form Preview Example

Sinai Hospital

[Attach Patient ID Sticker here]

Rubin Institute for Advanced Orthopedics/International Center for Limb Lengthening

2401 West Belvedere Avenue

Baltimore, Maryland

21215

410-601-8500/1-844-LBH-RIAO toll free

Preoperative History & Physical Examination Form

Patient Name ________________________________________________________________ Date ________________________

Date of Birth: ________________ Diagnosis_____________________________________________________________________

Proposed Surgical Procedure_________________________________________________________________________________

Surgeon___________________________________________________ Date of Surgery _________________________________

PAST MEDICAL HISTORY_____________________________________________________________________________________

__________________________________________________________________________________________________________

CURRENT MEDICATIONS

 

 

 

 

 

Medication

Dosage

Frequency

Medication

Dosage

Frequency

ALLERGIES_________________________________________________________________________________________________

PAST SURGICAL HISTORY

 

 

 

Date

Surgery

Hospital Name

Complications

SOCIAL HISTORY

Smoking _______________ Alcohol _______________ Caffeine _______________

REVIEW OF SYSTEMS - Check Box if Applicable

 

 

 

 

 

CardiovascularNone

 

Hematologic

None

PulmonaryNone

Neurologic/MSNone

Hypertension

 

Sickle cell disease/trait

Asthma

TIA or stroke

Angina/chest pain

 

Coagulopathy

 

Smoking history

Seizures

MI/CAD

 

Transfusion

 

COPD/emphysema

Neuromuscular disease

Arrhythmia/palpitations

 

Accepts transfusion

Sleep apnea

Cerebrovascular disease

CHF

 

Anemia

 

SOB

Arthritis

Valve disease

 

Cancer

 

Cough/productive cough

Dementia/Alzheimer's

Peripheral vascular disease

Chemotherapy

 

Wheezing

Elevated ICP

Pacemaker/AICD

 

 

 

 

PND/orthopnea

Loss of consciousness

Cardiac surgery

 

GI/Renal/EndocrineNone

Tuberculosis

Back problems

Coronary stents

 

Thyroid disease

 

 

 

Muscular dystrophy

Poor exercise tolerance

 

Diabetes I or II

 

 

 

Paralysis

 

 

 

Obesity

 

 

 

Syncope

AnesthesiaNone

 

Heartburn/reflux

 

 

 

 

Family history of problems

Hepatitis

 

Comment on positives or symptoms not listed:

Previous anesthesia

 

Renal insufficiency

 

 

 

 

 

complications

 

Recent steroid use

_____________________________________________________

 

 

 

Nausea/vomiting

 

 

 

 

GYN

 

Urinary tract infection

_____________________________________________________

LMP __________________

 

 

 

 

_____________________________________________________

Tubal ligation

 

 

 

 

 

 

 

 

PEDIATRICS Recent URI/Illness Prematurity Congenital Anomaly Apnea

Page 1 of 2

Sinai Hospital

 

 

Rubin Institute for Advanced Orthopedics/International Center for Limb Lengthening

[Attach Patient ID Sticker here]

2401 West Belvedere Avenue

 

 

Baltimore, Maryland 21215

Patient Name:____________________________________________ Date of Birth: __________

410-601-8500/1-844-LBH-RIAO toll free

Preoperative History & Physical Examination Form

PHYSICAL EXAM

Sex

Race

Age

Height

Weight (KG)

BP

Pulse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Resp

Temp

General appearance ______________________________________________________________________________________

HEENT

PERRLA

EOMI

No Lymphadenopathy

No JVD

O/P WNL

 

Thyroid WNL

TM WNL

 

 

 

Abnormal:

 

 

 

 

 

__________________________________________________________________________________________________________

Cardiovascular RRR S1S2 S3 S4

Abnormal:

__________________________________________________________________________________________________________

Pulmonary Lungs CTA B/L

Abnormal:

__________________________________________________________________________________________________________

GI

Abd Benign - Normoactive BS

No Hepatosplenomegaly

Abnormal:

 

 

__________________________________________________________________________________________________________

Extremities

No Clubbing

No Cyanosis

No Edema

Abnormal:

 

 

 

__________________________________________________________________________________________________________

Musculoskeletal

NML Muscle Tone

NML Strength

Abnormal:

 

 

___________________________________________________________________________________________________________

Neurological

CN II-XII intact

NML Mood

Abnormal:

 

 

___________________________________________________________________________________________________________

Genitalia/Rectum

Deferred

No masses

Heme negative

Abnormal:

 

 

 

___________________________________________________________________________________________________________

ASSESSMENT _____________________________________________________________________________________________

___________________________________________________________________________________________________________

The surgery proposed for this patient is low / intermediate / high risk.

The patient represents low / intermediate / high risk of cardiac mortality because of minor / intermediate / major clinical predictors. ________________________________________________________________________________

PLAN Further testing for this patient IS NOT recommended. The patient may proceed directly to surgery.

Further testing IS recommended for this patient. The following test(s) are to be obtained prior to the planned surgical procedure:

________________________________________________________________________________

MD/PA/NP Name (PRINT) ___________________________________ Date ________________________________

Provider Signature____________________________________ Phone Number (_________)____________________

FAX COMPLETED FORMS ASAP:

Patients of Dr. Herzenberg, Dr. Standard, Dr. Siddiqui, and Dr. Bibbo: 410-601-9575

Patients of Dr. Conway: 410-601-9576

PRE-OP H&P EXAM FORM REVISED 07-06-16

Page 2 of 2

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pre op physical form completion process shown (step 1)

2. Right after the last array of fields is done, go to type in the relevant details in these: Date, Surgery, Hospital Name, Complications, Smoking Alcohol Caffeine, SOCIAL HISTORY REVIEW OF SYSTEMS, None Hematologic Sickle cell, Pulmonary None Asthma Smoking, and NeurologicMS None TIA or stroke.

pre op physical form conclusion process explained (stage 2)

Regarding Hospital Name and Smoking Alcohol Caffeine, make sure you get them right in this section. The two of these are the most significant fields in the PDF.

3. The next stage is normally hassle-free - fill out all the form fields in SOCIAL HISTORY REVIEW OF SYSTEMS, None Hematologic Sickle cell, Tubal ligation, Pulmonary None Asthma Smoking, NeurologicMS None TIA or stroke, and Page of to conclude this segment.

Step no. 3 for completing pre op physical form

4. To move forward, this section requires completing a couple of empty form fields. Examples of these are Sinai Hospital Rubin Institute for, Patient Name Date of Birth, Attach Patient ID Sticker here, Preoperative History Physical, PHYSICAL EXAM, Sex, Race, Age, Height, Weight KG, Pulse, Resp, Temp, EOMI, and No JVD, which you'll find integral to going forward with this particular document.

Part no. 4 of filling out pre op physical form

5. To finish your document, the particular segment requires several additional blank fields. Entering No Clubbing, Lungs CTA BL, No Hepatosplenomegaly, Abd Benign Normoactive BS, General appearance HEENT Abnormal, Deferred, NML Muscle Tone, Heme negative, CN IIXII intact, NML Strength, No Cyanosis, No masses, NML Mood, and No Edema will conclude everything and you'll be done in an instant!

Filling out part 5 of pre op physical form

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