Dear Doctor:
_________________________________________, is scheduled to undergo
surgery on the following date : ____________________________________.
Prior to surgery, our anesthesiologists’ request:
This should include:
 H&P
 EKG (40 and older); chest x-ray (only if clinically indicated)
 LAB
 CBC, Platelet count, PT, PTT
 Urinalysis
 HIV, Hepatitis B & C tests.
 Pregnancy test (if applicable)
 Chem panel to include the
-Routine renal and hepatic tests, including
electrolytes
-Calcium
-Thyroid function T3 & T4 & TSH
 Other tests you determine to be clinically indicated.
Please complete the enclosed pre-surgical evaluation form and return it with the written
results of all laboratory studies.
The H & P and all lab work, EKG and other results must be received by us, 14 days prior
to surgery date.
PLEASE DO NOT DELETE ANY OF THE ABOVE REQUESTED TESTS AND
PLEASE REVIEW AND “SIGN OFF” ON ALL LABS, X-RAYS AND EKG
REPORTS.
You may FAX the H&P, clearance for surgery and pertinent laboratory results to (310)
278-0114. Thank you for your cooperation. Lic#G15529
Yours very truly,
Robert Kotler, MD, FACS
Pre-Operative Medical History and Physical Examination
Patient’s Name:____________________________________________________________Date:_____________
Chief Complaint:_____________________________________________________________________________
History of Present Illness:____________________________________________________________________
Illness:______________________________________________________________________________________
Proposed Surgical Procedure(s):_____________________________________________________________
_____________________________________________________________________________________
Pertinent Medical History:
Current Medications:
Allergies:
1.__________________________
_____ None
_____ Codeine
2.__________________________
_____ Penicillin
_____ Morphine
3.__________________________
_____ Sulfa
_____ Compazine
4.__________________________
_____ Tetanus
_____ Iodine
5.__________________________
Medical Disorders:
_____ AIDS
_____ Anesthetic Reaction
_____ Asthma
_____ Bleeding/Clotting Disorder
_____ Cancer
_____ Coronary Artery Disease
_____ Diabetes
_____ Rheumatoid Disease
OB/GYN History: LMP
Social History:
GR
_____ Hepatitis
_____ High Blood Pressure
_____ Past M.I.
_____ Peripheral Vascular Disease
_____ Psychiatric Disorder
_____ Pulmonary Disease
_____ Drug Addiction
_____ Other
P
AB
Living Children
Cigarettes
_______________ packs per day
Alcohol
_______________ drinks per day/wk
Drug abuse _______________
Surgical History:
Type of Surgery
1.__________________________________________________________________________________
2.__________________________________________________________________________________
3.__________________________________________________________________________________
4.__________________________________________________________________________________
5.__________________________________________________________________________________
PHYSICAL EXAMINATION:
AGE:
SEX:
HEIGHT:
BP:
P:
R:
WEIGHT:
HEENT:
GLANDS:
NECK:
CHEST:
BREASTS:
CARDIO:
ABD:
GU/RECTAL:
EXTREMITIES:
SKIN:
CNS:
IMPRESSION/DIAGNOSIS:
I have reviewed all pre-operative lab, x-ray and EKG results. [circle one]
YES
NO
Patient is medically cleared for proposed procedure(s).
YES
NO
PHYSICIAN’S SIGNATURE:
DATE:
ADDRESS:
PHONE NUMBER:
PRINT NAME:
[circle one]