History & Physical Form This form is a history and physical form. The entire form must be completed for an appointment to be scheduled. History & Physical Form If you are human, leave this field blank. Admitting MD: Name: Diagnosis: Date of Procedure: Proposed Procedure (If applicable): History - Present Complaint: Current Medications: Past Medical History Allergies: Yes No Previous Surgery Hospitalizations: Yes No Immunizations Up to Date: Yes No Family History Anest. Rxn: Yes No Bleeding Yes No Other Pertinent: Social History Pertinent: Yes No Physical Examination Height (cm) Weight (kg) Eyes Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Ears, nose, mouth Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Cardiovascular Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Respiratory Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Gastrointestinal Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Genitourinary Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Musculoskeletal Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Skin Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Neurologic Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Psychiatric Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Hematologic/Lymphatic Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Other Examined and WNL Examined and Note WNL Exam Deferred Abnormalities Abnormalities/deferment explained here by system number: Laboratory Hgb/Hct (If applicable) Additional Information Additional Information: Please fill this out with any information that did not fit above, such as positives from the review of systems (R.O.S.) Signature Clear Submit
