Pre-Anesthesia Medical Examination History
[textarea cols=80 rows=40 fillable="true"] ***Age*** year-old ***male/female*** ***scheduled for/will be evaluated for*** ***procedure*** due to ***indication for procedure***. ROS Patient denies ***lightheadedness/chest pain, chest pressure or chest discomfort/palpitations/shortness of breath/nausea/diaphoresis/wheezing/smoking*** during rest and/or exercise during the past six months. Positive symptoms include ***none/lightheadedness/chest pain, chest pressure or chest discomfort/palpitations/shortness of breath/nausea/diaphoresis/wheezing/smoking*** Patient is capable of exertion such as ***climbing a flight of stairs/walking uphill/heavy housework/other*** without experiencing anginal symptoms. PMH/PSH PAME ORIENTED MEDICAL HISTORY Bleeding tendency: ***no/YES (indicate)*** Currently taking steroids: ***no/YES*** Diabetes: ***no/YES*** History of embolic disease: ***no/YES (specify)*** Family history of malignant hyperthermia: ***no/YES*** Glaucoma: ***no/YES*** Hepatitis or HIV risk: ***no/YES*** Indication for cardioprotective Beta-blocker: ***no/YES*** Needs SBE prophylaxis: ***no/YES*** Other significant past medical history includes: ***none/cardiac disease/COPD/asthma/renal disease*** PAME ORIENTED SURGICAL HISTORY Prior surgical procedures include: ***none/specify*** [/textarea]
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