A physician office form is a document used in physician offices to send their patients to hospitals for tests and procedures. The form has to be filled for admission for lab tests, x-rays hospital admissions and surgeries. Below is a sample physician form for patient’s short stay in hospital.
Sample Physician Office Form
History and physical examination:
Chief Complaint_______________ Admissions date_____________
Present illness____________ past illness__________ Cardio pulmonary_____________
Allergies_____________ Mental status_____________ Pelvic exam______________
If H&P completed prior to calendar day of admission complete update below:
( ) NO CHANGE to H&P
( ) CHANGE IN EXAMINATION ___________________________Necessity for procedure is still present? No_ Yes_ (If no, explain in progress note) _____________
Physician signature___________ Date____________
Procedure Note:
Date/Name of procedure_________________
Surgeon_____________ Assistant____________ Preoperative diagnosis_________
Post operative diagnosis_________ Findings__________ Complications ___________
Discharge Form:
Date____________ Time______________ Communication: None___ Yes Describe_____
Course in hospital ___________Home Care Diet: Regular__________ Other_________
Activity: No restrictions ______Restrictions _________Follow up Dr______________
Physician Signature____________ Date______________
