Loading
Form preview picture

Get Childrens National Hospital Surgical History & Physical - Interdisciplinary Patient Assessment 2019-2024

111 Michigan Avenue NW Washington DC 20010 Surgeon s office to complete the following Fax completed form to Date of surgery Pre-op diagnosis for surgery ICD-9 code Proposed procedure Surgical History Physical - Interdisciplinary Patient Assessment Chief Complaint History of Present Illness/Injury Is the Patient in Pain YES NO Wong-Baker Faces Pain Rating Scale Recommended for children 3 year Location Frequency If Yes complete Numeric Scale For older children and adolescents Duration Character Dull Sharp Throbbing Review of Systems circle if the patient has had a recent Cough Rhinorrhea Fever Pneumonia in preceding 4 weeks Diarrhea Nausea/Emesis Other Call Pre-Operative Care Clinic 202 476-5966 or Surgeon s office if the following Wheezing in the past week Recent fever 100.7oF or 38oC Pneumonia in the prior 4 weeks Past Medical / Surgical History circle if the patient has or has had Asthma/Reactive Airway Disease GERD Congenital heart disease Heart murmur Prematurity weeks Family History/Psychosocial Assessment Allergies/Reactions Yes No Bleeding Disorders / Tendencies Yes Family h/o anesthesia problems Yes No No If Yes to above describe Immunizations Up To Date Yes No Date of Last Menstrual Period N/A Current Medications PLEASE TURN OVER Hnp HNP Revised Jan* 09 Page 1 of 2 Legend Place an X if abnormal if normal and leave blank if not examined* Physical Exam Temp HR RR BP / HT WT HC Mandatory Cardiovascular Lungs If Applicable General Appearance State Mouth / Teeth / Pharynx Skin / Scalp Head / Fontanel Lymph Nodes Ears Abdomen Skeletal Back Hip Extremities Eyes Genitals Neurological Development / Growth Nose Anus / Rectum Other describe Labs / Radiology if pertinent Assessment Medical or Surgical Indications for Admission Plans Education must be checked Diagnosis Medications Treatment Plan discussed and reviewed with patient / family I certify that this patient is medically cleared for surgery Resident/Fellow Signature Print Name Mandatory Physician/LIP Signature Print Name Date 24 Hour Update My signature attests that indications and plans for surgery are unchanged* Surgery Attending Signature Date Print Name.

How It Works

Form rating
4.8Satisfied
84 votes

Tips on how to fill out, edit and sign Childrens National Hospital Surgical History & Physical - Interdisciplinary Patient Assessment online

How to fill out and sign Childrens National Hospital Surgical History & Physical - Interdisciplinary Patient Assessment online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

The times of terrifying complex tax and legal documents have ended. With US Legal Forms the whole process of completing legal documents is anxiety-free. The best editor is right at your fingertips offering you various advantageous tools for filling out a Cnmc Registeration Form Download. These tips, with the editor will guide you with the whole process.

  1. Hit the Get Form button to start enhancing.
  2. Turn on the Wizard mode on the top toolbar to get additional tips.
  3. Fill each fillable area.
  4. Be sure the data you fill in Cnmc Registeration Form Download is updated and correct.
  5. Include the date to the template with the Date function.
  6. Select the Sign button and create a digital signature. You will find 3 available options; typing, drawing, or capturing one.
  7. Make sure that each field has been filled in properly.
  8. Select Done in the top right corne to save and send or download the file. There are several alternatives for getting the doc. As an instant download, an attachment in an email or through the mail as a hard copy.

We make completing any Cnmc Registeration Form Download much faster. Get started now!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Childrens National Hospital Surgical History & Physical - Interdisciplinary Patient Assessment

If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.