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MEDICAL CENTER EYE CLINIC
Date of Surgery:
PRE-OPERATIVE HISTORY & PHYSICAL
Past Ocular History
Past Medical History
Past Surgery History
Patient complains of poor vision in
eye(s), and activities of daily living are adversely affected,
particularly in the areas of:
CHRONIC ILLNESSES (See Diagnoses)
Mental Status: Other:
BP P R
This patient is an appropriate candidate to undergo the proposed procedure with chosen level
of sedation in the ASC. Risks, benefits and possible complications and alternatives have been discussed with the
patient. I have evaluated the patient for risks associated with the planned anesthesia and the procedure to
be performed and found the patient an acceptable candidate.
H&P current and valid.
Based on my evaluation of the patient, the risk of the planned anesthesia and the procedure
to be performed, I have found the patient to be an acceptable candidate.
ADDITIONAL MEDICATIONS AND/OR DRUG ALLERGIES - - CONTINUED