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Get Hartford Hospital HH 571048 2012-2024

TING DIAGNOSIS: ANESTHESIA PREFERENCE: (LOCAL, GENERAL, REGIONAL) PROPOSED OPERATION/PROCEDURE Specialists involved in patient’s care: HPI: PAST HISTORY: DRUG ALLERGIES: NONE LIST: MEDICAL: SURGICAL: FAMILY: REVIEW OF SYSTEMS: NWL Abnormal/ Comment General: HEENT: Neck: Cardiovascular: Pulmonary: GI: GU: Extremities: Skin: Neuro: Tobacco Use: ____________________________________________ If yes, smoking cessation counseling provided Yes No Alcohol Use: _________________________.

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