Plymouth Family Physicians

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920.893.0526 Fax: 920-893-9409
1000 Eastern Avenue, Plymouth, WI 53073
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Preoperative History & Physical

Please complete this ENTIRE form and bring it with you to your scheduled appointment.  This is used to up date your medical history and reduce the risks of complications from surgery and anesthesia.

Thank you for your assistance.

  • Date Format: MM slash DD slash YYYY
  • Past Medical History (Please list year each issue occurred)

  • Date Format: MM slash DD slash YYYY
  • Medication Information

  • Social History

  • Family History

    Please list any illness in your family members including heart disease, stroke, diabetes, cancer, high blood pressure, high cholesterol levels, lung disease, liver or kidney disease, depression or suicide.
  • Medical Problems

    Please check any problems listed below that you have had and note any details including when this occurred.
  • Please review your information before submitting.

    Plymouth Family Medical Associates use HTTPS encryption on their site to ensure that your medical information is secure.

PLEASE BRING ANY IMMUNIZATION DATES FOR TETANUS, PNEUMOVAX OR RECENT FLU SHOTS IF YOU HAVE THESE RECORDS. 

PREOPERATIVE CLEARANCE MAY REQUIRE:  LABS, XRAYS OR EKGs.  WE WILL ALSO DO OUR BEST TO UPDATE ALL RECOMMENDED HEALTH MAINTENANCE ITEMS AT THE TIME OF THIS VISIT OR, IF TIME IS LIMITED, WE WILL SCHEDULE THESE BEFORE YOU LEAVE. 

Plymouth Family Physicians, S.C.

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