Pre- Surgery Medical History & Physical for Cataract Surgery

Pre- Surgery Medical History & Physical for Cataract Surgery

Patient Name: __________________________________________ Date: ________________________ Doctor's Name (Please Print): ____________________________________________________________ Allergies: N /A Latex Medication

History of Present Illness

Past Surgeries

Past Medical History (include date of inset)

Cancer Cardiac Malignant Hyperthermia Mitral Valve Prolapse Hypertension Respiratory Kidney Sleep Apnea Diabetes Morbid Obesity Stroke/ CVA Pacemaker Seizures Hepatitis Alpha-1 Block used (past or present) (eg. Flomax, Hytrin) ____________________________

Medications (prescription & over the counter)

Name

Dose Frequency

Specific Abnormalities Lab __________________________________________ ECG _________________________________________ Other ________________________________________

Other

Fit for Surgery

Physical Exam B/P ______________

P ______________

Weight _____________ kg

Height_____________cm

General Head & Neck Lungs Heart Abdomen

Normal Abnormal _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

Doctor's Signature _________________________________ Phone Number / Stamp ______________________

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