Medical Assessment Form GP Form Patient PhotoAccepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 20 MB.Patient Number*Family Name: (KH/EN)*Given Name/s: (KH/EN)*Medical History (Please Check)Heart Disease includingHypertension Yes No Chest Pain Yes No Shortness of breath Yes No Other cardiovascular NotesRespiratory History includingAsthma Yes No Cough Yes No COPD Yes No Other respiratory NotesMetabolic history includingDiabetes Yes No Unknown Thyroid Disease Yes No Kidney Failure Yes No Other metabolic NotesInfections includingSkin Yes No HIV Yes No Hepatitis No Yes - Unknown Type A B C Unknown Pulmonary TB Yes No Other Infectious Disease NotesAdditional HistoryTaking Medications For None Unknown Heart Hypertension Lung Stomach Diabetes Thyroid Disease Pain Other Any Past Operations Yes No Any Allergies Yes No Mental Health Yes No MedicationsDescribe past operationsDescribe AllergiesDescribe past Mental HealthTestsO2 SaturationTemperatureFasting GlucoseB.P.Pulse RateHeart SoundWE WILL NOT OPERATE ON PATIENTS WITH A B.P. OF SYSTOLIC ABOVE 180 OR DISTOLIC ABOVE 140 mmHg or Fasting Glucose above 14 mmol/LOther testsCXR No Yes E.C.G. No Yes Blood test No Yes Other FindingsClinical ExaminationCVS No Yes Respiratory Normal Not Normal Anaemic/Jaundice No Yes What not normal about the patients respiratory?SummaryCAN PATIENT LAY DOWN FLAT FOR ONE HOUR YES NO SURGERY STATUS* PATIENT IS FIT FOR SURGERY PATIENT IS NOT FIT FOR SURGERY PATIENT REFUSED SURGERY FIT FOR SURGERY - DID NOT SHOW UP SURGERY IS SCHEDULED FOR* CATARACT RIGHT EYE CATARACT LEFT EYE PTERYGIUM RIGHT EYE PTERYGIUM LEFT EYE OTHER SURGERY RIGHT EYE OTHER SURGERY LEFT EYE PATIENT NEEDS TO BE REVIEWED FOR Nothing Diabetes Hypertensive Asthmas/COPD Nutrition Infection Other HAS THE PATIENT SIGNED THE CONSENT FORM* YES NO HAS THE PATIENT HAD THEIR PHOTO TAKEN AND SAVED* YES NO OtherDate DD slash MM slash YYYY
