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MEDICAL CENTER EYE CLINIC
Patient Name:
DOB:
Date of Surgery:
Surgeon:
Primary Physician:
PRE-OPERATIVE HISTORY & PHYSICAL
DIAGNOSIS:
Planned Surgery:
Past Ocular History
Past Medical History
Past Surgery History
PO HX:
PM HX:
PSX HX:
HPI:
Patient complains of poor vision in
-
-
eye(s), and activities of daily living are adversely affected,
particularly in the areas of:
-
-
-
-
-
-
-
other:
This surgery:
CHRONIC ILLNESSES (See Diagnoses)
Reaction
REGULAR MEDICATIONS
DOSE
SCHEDULE
DRUG ALLERGIES
NAUSEA
VOMIT
RASH
SHOCK
OTHER
PHYSICAL EXAMINATION
Mental Status: Other:
Heart: Other:
Lungs:
Other:
Other:
BP P R
Plan:Schedule for
surgery
EYE EXAMOD
VA:BAT:
IOP:
Cataract:
NS
CS
PSC
BRUN
ASC
Fundi:
OS
VA:BAT:
IOP:
Cataract:
NS
CS
PSC
BRUN
ASC
Fundi:
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.
Signature
Date:
Time:
PRE-SURGICAL/PRE-ANESTHESIA ASSESSMENT:
H&P current and valid.
Comments:
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.
Signature
Date:
Time:
PATIENT LABEL
ADDITIONAL MEDICATIONS AND/OR DRUG ALLERGIES - - CONTINUED