SALEM LASER AND SURGERY CENTER

Patient Name
Date of Surgery

Surgeon
Primary Physician

PRE-OPERATIVE HISTORY & PHYSICAL


HPI:
PMHx:
POHx:

Reaction
REGULAR MEDICATIONS
         DOSE
    SCHEDULE
       DRUG ALLERGIES
NAUSEA
VOMIT
RASH
SHOCK
OTHER
PHYSICAL EXAMINATION

Mental Status: Normal Other:

Heart: RRR w/o M Other:

Lungs: Clear Other:

Other:
EYELID EXAM OD
OS

Assessment:
RUL LUL RLL LLL

Plan:
RUL LUL RLL LLL

Signature
Date:
Time:

REASSESSMENT:

Signature
Date:
Time:

PATIENT LABEL





ADDITIONAL MEDICATIONS AND/OR DRUG ALLERGIES - - CONTINUED


Patient Name:
DOB:


Reaction
REGULAR MEDICATIONS
         DOSE
         SCHEDULE
       DRUG ALLERGIES
NAUSEA
VOMIT
RASH
SHOCK
OTHER

HISTORY / PHYSICAL - ADDITIONAL COMMENTS


PATIENT LABEL