Digestive Conditions, Miscellaneous

(Tuberculous Peritonitis, Inguinal Hernia, Ventral Hernia, Femoral Hernia,
Visceroptosis, and Benign and Malignant New Growths)

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

1. Describe all hernia surgery and results.
2. For malignancy, state type of treatment, dates of treatment, including last date of treatment if it has ended.
3. For peritoneal tuberculosis, state date of diagnosis, treatment, and date on which inactivity was established.

C. Physical Examination (Objective Findings): Address each of the following and fully describe current findings:

1. For inguinal or ventral hernia, state whether reducible, how well supported by truss or belt, and whether irremediable or inoperable.
2. For ventral hernia, state size of hernia, extent of diastasis of recti muscles, status of muscles and fascia of abdominal wall.
3. All residuals of malignancy, including residuals from treatment.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

Signature:

Date: