Notes:

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MEDICAL CENTER EYE CLINIC

Patient Name:
Date of Surgery:  

Surgeon:
Primary Physician:

PRE-OPERATIVE HISTORY & PHYSICAL
DIAGNOSIS:    
Planned Surgery:


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 EXAM OD  

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


Patient Name:
DOB:


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

HISTORY / PHYSICAL - ADDITIONAL COMMENTS


PATIENT LABEL