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 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 If you are human, leave this field blank.
