Pre-Anesthesia Medical Examination History

This is a history template.

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***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***

Pre-Anesthesia Medical Examination History

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