Poconoambulatorysurgerycenter.net

Patient Name: ____________________________________________ Surgery Date: ____________________________________________ Operative Procedure: ______________________________________ ICD 9 Diagnostic Code: ____________________________________ Medical Clearance?  No  Yes, with __________________
PRE SURGICAL TESTING: MUST BE COMPLETED a minimum of 7-10 days before scheduled surgery date.
Form to be completed by surgeon. Please check all categories below which apply to patient.
DISEASE PROCESS MODIFIERS: Prior EKG over age 40 good for 3 months

 History of Diabetes: (FBS, POTASSIUM, EKG) 250.00
HISTORY OF CARDIAC DISEASE: Prior EKG good for 6 mos., diabetic patient 3 months

 Coronary Artery Disease: (CBC, CREATININE, POTASSIUM, EKG) 414.00  Hypertension: (CBC, CREATININE,
POTASSIUM, EKG) 401.9
 Renal: (CBC, CREATININE, POTASSIUM, EKG) 404.00  Angina: (CBC, CREATININE, POTASSIUM,
EKG) 413.9
 Myocardial Infarction: (CBC, CREATININE, POTASSIUM, EKG) 412  Diuretics: (CBC, CREATININE, POTASSIUM,
EKG) 276.0
HISTORY OF PULMONARY DISEASE: Prior EKG good for 6 mos., diabetic patient 3 months

 COPD: (POTASSIUM, EKG, CXR) 491.21  CHF: (POTASSIUM, EKG, CXR) 428.0
 LVF w/ pulmonary edema: (POTASSIUM EKG, CXR) 428.1  Emphysema: (POTASSIUM, EKG, CXR) 491.20
 Bronchitis: (POTASSIUM, EKG, CXR) 491.21  Asthma: If acute at PSS (POTASSIUM, EKG, CXR) 415.19
HISTORY OF LIVER DISEASE:
 Chronic, long term : (CBC, CREATININE, LFT, PT, PTT) 573.9  ETOH Abuse: (CBC, CREATININE, LFT, PT, PTT) 571.3
 Hepatitis: (CBC, CREATININE, LFT, PT, PTT) 573.3  Liver failure: (CBC, CREATININE, LFT, PT, PTT) 571.9
CATARACT CASES: If MAC: General Anes or non-cataract ophthalmology cases, default to disease process modifiers
 Diabetic: (FBS, POTASSIUM) 250.00  Renal History: (POTASSIUM) 404.00
 Cardiac History: (POTASSIUM) 414.00

OTHER FACTORS:
 Known Bleeding Disorder: (CBC, PT, PTT, BLEEDING TIME) 286.9
 Leukemia: (CBC, PT, PTT) 208.90
 Cancer: (code specific): (CBC) ____________
 All Menstr. Females, all GYN procedures: (BHCG) V72.40
(H&H) V78.0
MEDICATION MODIFIERS:
 Coumadin: (PT/INR) 286.9
 Digoxin: (CREATININE, POTASSIUM, DIGOXIN LEVEL) E942.1
 Steroids:

Other: ____________________________________________
Copies to: _________________________________________
Surgeon Signature: _________________________________
DEAR PATIENT: Please plan to spend about 45 minutes for your pre-operative visit. Screenings are done daily Monday through Friday
between the hours of 9:00 a.m. and 2:00 p.m. We welcome the opportunity to participate in your medical care. We depend on your
surgeon to evaluate your health and order the appropriate studies. We depend on YOU to provide accurate health screening information on
this form. PLEASE COMPLETE THE ATTACHED SURVEY BEFORE YOU ARRIVE. The Staff of Pocono Ambulatory Surgery
Center.
ASC forms Pre OP Labs, jm 06/99,7/99,3/00,9/01,5/02,3/03,9/04,6/05,1/06,4/07,5/07, 05/08, 11/09, 06/11Right Protected

Source: http://www.poconoambulatorysurgerycenter.net/Portals/0/documents/PRE_SURGICAL_TESTING.pdf