MEDICAL RECORD. Last and given name(s)... Personal Identification Number PESEL.. Residence address... Phone number..
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1 MEDICAL RECORD Last and given name(s)... Personal Identification Number PESEL.. Residence address... Phone number The person authorised by the patient to be contacted and receive information concerning the condition and health services provided Full name Address. Phone number.. I hereby authorise Mr(s) holder of the ID card no...series.., Personal Identification Number PESEL.. To receive my medical record in case of my death. date patient s signature Diagnosis made by the referring physician Type of procedure Admission date Discharge date... 1
2 History and physical examination immediately preceding the procedure Body weight..height..temperature.. Premedication recommended Premedication was administered at nurse s signature anaesthesiologist s signature DESCRIPTION OF THE PROCEDURE
3 Observation at the recovery room Blood pressure Pulse Breath Saturation Temperature The answer NO renders the discharge impossible Total regain of awareness Regain of defensive reflexes ( swallowing, cough ) Regain of motor actions and normal behaviour The answer YES renders the discharge impossible Abnormal parameters ( blood pressure, pulse ) Complications during the procedure Unexpected prolongation of the procedure Post-operative bleeding Breathing distortions Stridor Nausea or vomiting POST-OPERATIVE OBSERVATION CONCLUSIONS The patient qualifies to be discharged home The patient qualified for further hospitalization at the department The patient qualifies to be transported to a specialist hospital.. date and signature of the operator anaesthesiologist s signature 3
4 HOSPITAL DISCHARGE CARD Discharge summary dated.. 4
5 QUALIFICATION CARD FOR SURGERY Full name Address Personal Identification Number PESEL HISTORY PHYSICAL EXAMINATION LOCAL CONDITION DIAGNOSIS PLANNED PROCEDURE Patient according to the ASA class of.. 5
6 CRITERIA EXCLUDING ONE-DAY SURGERY Ø the ASA class of 3,4,5 Ø blood diseases, haemorrhagic conditions Ø metabolic diseases ( diabetes ) Ø active infection ( particularly of respiratory tract ) Ø undiagnosed or uncontrolled heart disorder Ø history of convulsion within the last 6 months Ø malignant hyperpyrexia Ø increased risk of post-operative bleeding The patient received the information brochure concerning the surgery, anaesthesia and preparation to the procedure as well as the post-operative care Date. Doctor s signature Any comments of the anaesthesiologist : 6
7 QUESTIONNAIRE Please provide all information in block letters or circle the correct answer Ø Weight.Height Age. Ø Have you been under medical care due to a chronic disease recently?.. Ø Are you pregnant?( date of the last menstruation ) Ø Do you take any medicines permanently?... Ø Have you taken any anti-flu, analgesic, anticoagulant, anti-rheumatic medicines within the last 10 days? Ø What surgeries have you undergone so far and which year? Ø Did anything particular happen in relations to these procedures? Ø Have your relatives had any complications following anaesthesia? Ø Have you ever had your blood transfused? Ø Were there any complications? Do you know that you are currently or have suffered for any of the following diseases? Ø Muscle diseases or muscle flaccidity? Ø Do or did your relatives suffer from muscle diseases or muscle flaccidity? Ø Heart diseases, e.g. heart attack, coronary disease, heart disease, myocarditis, arrhythmia, other? Ø Are you suffering from hypertension? Ø Lung and respiratory diseases ( tuberculosis, coniosis, pneumonia, empysema, asthma)? Liver diseases ( hepatitis, necrosis, other)? Ø Do you suffer from lower extremity varices? Ø Kidney diseases ( nephrolithiasis, inflammation, other )? 7
8 Ø Metabolism disorders (e.g. diabetes )? Ø Thyroid diseases ( e.g. hyperthyroidism, hypothyroidism, thyroid enlargement, other)? Ø Eye diseases ( e.g. cataract, glaucoma, other)? Ø Nervous system diseases ( e.g. epilepsy, paresis, other )? Ø Have you been treated for mental disorders ( e.g. depression, neurosis, other)? Ø Bone system diseases ( of the spine, joints, other)? Ø Do you suffer from stomach or duodenal ulcerative disease? Ø Blood diseases or coagulation disorders ( e.g. predisposition to haematomas, nose bleeding, other )? Ø Allergies ( hay fever, rashes, hypersensitivity to food, medicines, adhesive plaster )? Ø Do you suffer from another diseases not listed above? What disease?... Ø Do you wear dentures ( e.g. crowns, bridges, removable dentures, other)? Ø Do you have loose teeth? Ø Do you smoke regularly? Ø Do you drink alcohol regularly? Ø Are you used to any medications? Ø Do you hear badly? 8
9 EPIDEMIOLOGICAL HISTORY For infection with HBV, BCV virus (concerns the last 6 months) Warsaw, on / /. Full name... Date of birth... Yes No 1. Have you suffered from hepatitis? 2. Have you been treated in other Healthcare Centres, including private doctor s offices? 3. Have you had contact with a hepatitis B, hepatitis C patient? 4. Have you been administered injections, infusions, transfusions?* 5. Have you undergone any procedure disturbing skin layers (biopsies, punctures, needle treatment, surgeries, blood sample collection)? 6. Have you been vaccinated for hepatitis B? if yes, how many times? 7. Have your Hbs antigen and anti-hcv antibodies been assessed? 8. Have you had endoscopy examinations performed? 9. Have you used services of dentistry offices? (tooth extraction, tooth filling, concrement removal) 10. Have you used the services of ophthalmologists? 11. Have you used hairdresser or beautician s services? (manicure pedicure, tattoo, earrings, razor shaving, etc.) If yes, when? (signature of the person gathering the history) (patient s signature) * underline as appropriate 9
10 INFORMED CONSENT TO ANAESTHESIA Patient s data Full name Date of birth Anaesthesia 1. Surgery.. 2. Suggested anaesthesiological procedure. Ø Intubation Ø Laryngeal mask airway (LMA) Ø GA mask 1. I have fully assessed the patient s condition prior to the anaesthesia. 2. I explained to the patient the nature of the anaesthesia to be administered during the procedure with particular consideration of : Ø Anaesthesiological procedure Ø Side effects following the anaesthesia Ø Risk factors 3. I provided the patient with enough time to complete the anaesthesiological questionnaire... Anaesthesiologist s signature Date Consent to anaesthesia Your surgery should be performed under general anaesthesia. However, each and every general/local anaesthesia is bound with some complications and side effects. These are: 1. Acute heart attack which may be anaesthesia- or surgery-induced, particularly in patients with diagnosed coronary diseases. 2. Stroke which may be anaesthesia- or surgery-induced, particularly in patients suspected or diagnosed with coronary diseases or brain vessel diseases. 3. Aspiration pneumonia related with vomiting during the anaesthesia 4. Malignant hypertension which may be related to the anaesthesia 5. Abnormal reaction caused by allergy to medicines or transfusion. 6. Irreversible nerve damage during regional anaesthesia. 7. Pneumonia or atelectasis possibly caused by pre-existing upper respiratory tract infection. 9. Maintaining proper drainage of the respiratory tract during the anaesthesia may be related to damage to teeth, oral mucosa, lips. 11. A particular position of the patient during the surgery may cause nerve damage or ulcers and bedsores. 12. During very long surgeries hoarseness or vocal cords damages may occur. 13. While waking up from the anaesthesia the patient may feel pain, and the following conditions may happen: unstable blood pressure, nausea/vomiting, arrhythmia and rarely dyspnoea, cyanosis and other disorders which will abate shortly thereafter. 10
11 The anaesthesiologist,, MD discussed with me the pre-, intra- and post-operative procedure today. During the discussion I could ask questions concerning the anaesthesia, post-operative care, risk related thereto and possibility of complications, and I received complete and understandable answers. Being aware of possible consequences to my health I hereby declare that I have not kept in secret any information concerning my condition, treatment to date and medicines I take. I give my consent having made independent decision and I had enough time to make such decision. I also give my consent to justified additional medical procedures such as: blood, plasma and other body liquid transfusions, additional access and change of anaesthesia if required. I hereby give my consent for the suggested treatment of the post-operative pain. I give the following restriction concerning the medical procedure: Patient s signature.. Date Witness signature 11
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PATIENT MEDICAL HISTORY PATIENT INFORMATION
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Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
PATIENT REGISTRATION
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Inflammatory Bowel Disease Medical Exam Questionnaire
Patient Name: MR: Date: Name DOB / / Age Marital Status Race Gender M / F Height Present Weight Usual Weight Insurance Managed Care Self referral Yes No Yes No Yes No Primary Care Physician Referring Physician
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
Anesthesia Preoperative Patient History
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New Patient Questionnaire
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Pre-Admission Testing Questionnaire
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SELF-REPORTING HEALTH HISTORY
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Adult Health History
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Date: New Patient Form First Visit Date:
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