Preoperative History and Physical Examination Form

Dear Medical Consultant,
UCLA Anesthesia Preoperative Evaluation Service
Medical Consultant Checklist
Your patient___________________is having surgery at the Jules Stein Operating Room.
Surgeon _______________________Type of Operation__________________________
Type of anesthesia: general anesthesia ____monitored anesthetic care (MAC)_____
Surgery Date: _________________ Due Date for Preop Documents_______________
Please fax the following required information AT LEAST ONE WEEK BEFORE
SURGERY DATE to the surgeon’s office at __________________________________
History and Physical: 1. Completed within one month of surgery date for all patients.
2. H&P form sent with this checklist preferred.
3. Dictated and other H&P forms should be dated, and
include a review of systems, physical exam, and MD signature.
EKG: 1. All men >50 & women> 60
and any age patient with cardiac, renal, pulmonary disease,
diabetes, or hypertension, fax EKG tracing with interpretation.
CXR: If patient has had recent pneumonia or CHF.
Pacemaker/AICD: Fax most recent pacemaker or AICD check.
Stress Test/
Echocardiogram: If the patient has had cardiac problems (AS, CAD, MI, CHF,
MVP, heart surgery, angioplasty, cardiac stents, irregular heart
beat, pulmonary hypertension) fax report of test results.* Please
see attached guideline for non-invasive cardiac testing
CBC: If the patient had chemotherapy in last six months, history of renal
failure, anemia, or bleeding tendency.
Electrolytes, BUN If patient has diabetes, renal failure, is on diuretics, digoxin, or
Creatinine, glucose: steroids or has a pacemaker
Thyroid Function: If patient is hyper/hypothyroid.
Liver Function: If patient has liver disease.
Sleep Study: If patient has sleep apnea.
Thank you for your cooperation!
Rev 9/21/11

Patient Name: ______________________ AGE ________ M / F
Date of Examination __________________ Date of Surgery: ______________
Medical History:
Allergies: NKDA ________________________
Medications: both prescription and over-the-counter (including doses):
_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ _______________________________
Alcohol _____ Drinks per_____ ( ) None
Street drugs ( ) Yes ( ) No ( ) Type: ___________
Blood/Fluid Precautions: ( ) Yes ( ) No
Past Surgical History/ Type of Anesthesia/ Complications:
1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
4. __________________________________________________________________________________
ROS: HEENT:
Sleep apnea or compromised airway ( ) Yes ( ) No CPAP: ( ) Yes ( ) No
O2? ( ) Yes ( ) No
Cardiovascular:
Walk 1-2 blocks: ( ) Yes ( ) No
Climb flight of stairs: ( ) Yes ( ) No
Prior MI ( ) Yes ( ) No
Palpitations ( ) Yes ( ) No
Prior CHF ( ) Yes ( ) No If Yes, when? ___________________
Angina ( ) Yes ( ) No
Angioplasty ( ) Yes ( ) No If Yes, when? ___________________
CABG ( ) Yes ( ) No If Yes, when? ___________________
Arrythmia ( ) Yes ( ) No If Yes, when? ___________________
PVD ( ) Yes ( ) No
Able to lie flat ( ) Yes ( ) No Number of pillows: ______________
Pacemaker ( ) Yes ( ) No Last check date [ ] __________
Exercise Tolerance: _______________________________________________________________________
Respiratory:
COPD ( ) Yes ( ) No
Chronic cough ( ) Yes ( ) No
Productive ( ) Yes ( ) No
Smoker ( ) Yes ( ) No Pack-years: ___________________
Other: _______________________________________________________________________
Gastrointestinal:
Renal:
GERD ( ) Yes ( ) No Controlled ( ) Yes ( ) No
Elevations of LFT’s ( ) Acute ( ) Chronic
Hepatitis ( ) Yes ( ) No Type ______________________
Other: ____________________________________________________________________
Dialysis ( ) Yes ( ) No Number of years __________________
CRI ( ) Yes ( ) No
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Patient Name ___________________________________________________

Gyne:
Possibility of untreated pregnancy ( ) Yes ( ) No
Last menstrual period: _______________________________
Endocrine:
Diabetes ( ) Yes ( ) No
Graves ( ) Yes ( ) No
Hypothyroid ( ) Yes ( ) No
CNS:
CVA ( ) Yes ( ) No When? _________ Residual? _________
Seizures ( ) Yes ( ) No Date of last seizure _________________
Family History:
Family history of anesthetic complications ( ) Yes ( ) No
Other:
Physical Examination: BP _____ Pulse ______ RR ______ T ______ Wgt _____ Ht: _______
HEENT:
Lungs:
Heart: Rate/minute:________________ Rhythm: _________________
Murmurs: ( ) Yes ( ) No If Yes, please attach last echo
Abdomen:
Extremities:
Neurological:
Laboratory: EKG ___________ Any change? ___________________ Date: _____________
ECHO _________ Ejection Fraction _______________ Date: ____________
Stress Test __________________________________________________ Date: ____________
CBC: __________________________________ Lytes: _________________
LFTs: ________________________________ TSH: ________________________
Patient’s medical condition is optimal for planned procedure: ( ) Yes ( ) No
Recommendations:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Signature of examining physician: _____________________________________ Date of exam: ____________
Printed Name: __________________________________________________ Telephone : _________________
H&Ps done by nurse practitioners and/or physician assistants need MD co-signature. Thank you.
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