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Patient to complete this information Patient s Name Birth date Today s date Referring Physician Primary Care Physician Age Occupation Retired, how long? Prior operations Medications Type Date Name Dose Have you had? Pneumonia Heart attack Kidney failure Rheumatic fever Hepatitis Cancer Ulcers Hiatal Hernia High Blood Pressure Gout Asthma Sleep Apnea Diabetes Medication Allergies: Latex Allergy? Yes No Contrast Allergy? Yes No Family History Mother s age: If deceased, cause: Father s age: If deceased, cause: Do you have a family history of? Heart disease Stroke Diabetes Cancer Aortic Aneurysm Personal History Marital Status: Single Widowed Divorced Married, number of years Number of children: Tobacco use: Yes No Current smoker Past smoker Packs per day: Year stopped Chew Alcohol use: Yes No 1 drink/week Daily

Patient to complete this information Do you have any of the following symptoms or concerns? GENERAL Fever.. Chills.. Weight loss... If so how much? SKIN Rash... Itching. Easy bruising. Head, Eyes, Ears Headaches.... Dentures.... Nose bleeds...... Glasses.. Hearing loss.. Cataracts... Chest/Respiratory Cough........... Shortness of breath.. Coughing up blood... Tuberculosis..... Heart Angina/Chest Pain... Passing out... Heart murmur... Elevated cholesterol. Palpitations.... Awakened at night short of breath. Sleep on more than one pillow... Ankle edema. Gastrointestinal Poor appetite. Nausea... Vomiting. Constipation.. Bloody stools. Black stools... Diarrhea. Gallstones.. Jaundice.

OVER Patient to complete this information Do you have any of the following symptoms or concerns? Urinary Do you awake to urinate?... If so how much? Once Twice Three or more times Painful urination... Frequent urination.... Kidney stones... Incontinence.. Erectile dysfunction.. Blood in urine Endocrine Diabetes. Thyroid abnormality..... Hot or cold intolerance. Hematologic Bleeding tendencies. Anemia... Musculoskeletal Arthritis Calf, thigh pain with walking Peripheral arterial disease... Foot sores.. Varicose veins Neuro-Psychologic Stroke.... TIA.. Seizures. Dizziness... Depression.

06-23-07 Leave Blank For MLP use Leave Blank For Surgeon s use History: Examination (Check if normal, circle and explain, if abnormal) Examination (Check if normal, circle and explain, if abnormal) Height Weight Vital Signs: Pulse Height Weight Vital Signs: Pulse Respirations BP / Respirations BP / CONSTITUTIONAL: Well developed, well-nourished CONSTITUTIONAL: Well developed, well-nourished NAD Caucasian AA Asian male female NAD Caucasian AA Asian male female SKIN: Warm Acyanotic SKIN: Warm Acyanotic No mass/lesions other No mass/lesions other HEENT: AT/NC PERRLA EOM s full HEENT: AT/NC PERRLA EOM s full Conjunctiva pink Dentition good dentures Conjunctiva pink Dentition good dentures Other NECK: Supple TML JVD Bruit Adenopathy NECK: Supple TML JVD Bruit Adenopathy Thyroid abnormality Carotid upstroke normal Thyroid abnormality Carotid upstroke normal CHEST/RESPIRATORY: Symmetric ventilation CHEST/RESPIRATORY: Symmetric ventilation Clear to percussion & auscultation Clear to percussion & auscultation

HEART: Apical rate regular HEART: Apical rate regular Normal left ventricular impulse Rub Normal left ventricular impulse Rub Murmur Murmur ABDOMEN: Protuberant Scaphoid ABDOMEN: Protuberant Scaphoid Soft/Non-tender Mass Bowel sounds Soft/Non-tender Mass Bowel sounds Hepato-splenomegaly Normal aortic pulsation Hepato-splenomegaly Normal aortic pulsation Other EXTREMITIES: FROM/No deformity Other EXTREMITIES: FROM/No deformity Strength/tone intact No edema Strength/tone intact No edema NEURO-PSYCH: Oriented x 3 Normal affect NEURO-PSYCH: Oriented x 3 Normal affect Motor/Sensory Cranial nerves Motor/Sensory Cranial nerves Pulses: Pulses: I have reviewed the ROS completed by on located in this chart. Assessment and Plan: I have reviewed the ROS completed by on located in this chart. Assessment and Plan: Signature: Date: Physician Signature: Date:

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