Patient Form

PATIENT INFORMATION

May we send information to your home address? *

Yes

No

Patient Last Name *

Patient First Name *

MI

Address *

City *

State *

Zip *

Home Phone

Work Phone

EXT

Cell Phone

Email *

Date of Birth *

Gender

F

M

Ethnic Origin

Referred By

Marital Status

S

M

D

W

Spouse’s Name

Phone No

If patient is under 18 years old: RESPONSIBLE PARTY

Last Name

First Name

MI

Address

City

State

Zip

Cell Phone

Home Phone

Work Phone

EXT

Email

Date of Birth

Gender

F

M

Ethnic Origin

For Workers’ Comp. case only: EMPLOYMENT INFORMATION

Employer’s Name

Phone No

Ext

Address

City

State

Zip

Patient's Occupation

If Applicable: PRIMARY INSURANCE INFORMATION

Insurance Company

ID#

Group#

Policy Holder

Birthdate

SS#

Home Address

Employer

Employer Phone

What procedure(s) are you interested in?

Have you ever seen another Doctor about this procedure?

Yes

No

If yes, what happened with this Doctor?

PERSON TO NOTIFY IN EMERGENCY:

Name *

Relationship *

Phone No *

I acknowledge that I am responsible for all the charges for services rendered to me.

PATIENT SIGNATURE *

DATE *

PATIENT MEDICAL HISTORY

Patient Name *

Date *

Age

Height

Weight

General Health

Good

Fair

Poor

If NOT GOOD please explain

PAST MEDICAL HISTORY

When was your last physical checkup?

List all ALLERGIES to medications.

Please list all PILLS OR MEDICATIONS you are now taking.

Do you take ASPIRIN regularly?

Yes

No

If YES , how often?

Have you taken STEROIDS OR CORTISONE in the past year?

Do you SMOKE?

Yes

No

How much?

Do you consume ALCOHOL?

Yes

No

How much?

List all PLASTIC SURGERY you have had.

List any other SURGERY OR INJURIES you have had

Have you had any PROBLEMS OR COMPLICATIONS after surgery?

Yes

No

If YES please explain

Have you had any UNPLANNED WEIGHT LOSS ?

Yes

No

If YES how many pounds?

Are you under MEDICAL TREATMENT at this time?

Yes

No

If YES please explain

If you are having breast surgery, have you had a recent MAMMOGRAM ?

Yes

No

If yes, was it normal?

Yes

No

HAVE YOU HAD ANY ILLNESSES WITH THE FOLLOWING:

High blood pressure

Yes

No

Heart Problems

Yes

No

Thyroid disease

Yes

No

Arthritis

Yes

No

Diabetes

Yes

No

Blood Disorders

Yes

No

Heart Attack

Yes

No

Ulcers

Yes

No

Bleeding Tendency

Yes

No

Nervous Disorders

Yes

No

Seizures

Yes

No

Other

Yes

No

Persistent Coughing

Yes

No

Other illnesses

List Current TREATMENT for any of the above

HAVE YOU EVER HAD ANY OF THE FOLLOWING:

A positive HIV test or AIDS test

Yes

No

Hepatitis or Yellow Jaundice

Yes

No

Bad reaction to general anesthetic

Yes

No

Allergic reaction to adhesive tape

Yes

No

Frequent boils or infections

Yes

No

Shortness of breath while walking

Yes

No

Significant emotional problems

Yes

No

Psychiatric treatment

Yes

No

Blood transfusion

Yes

No

Required large amounts of anesthesia for medical or dental procedures

Yes

No

Bad reaction of local anesthetic (novocaine, etc.)

Yes

No

Bruising easily

Yes

No

Large scarring or keloids

Yes

No

Slow or poor healer

Yes

No

Please explain all YES answers to the above

FAMILY HISTORY (Has any relative had):

High blood pressure

Yes

No

Cancer

Yes

No

Diabetes

Yes

No

Heart disease

Yes

No

Epilepsy

Yes

No

Lung disease

Yes

No

Kidney disease

Yes

No

Asthma

Yes

No

Blood disease

Yes

No

Mental disease

Yes

No

Breast Cancer

Yes

No

Patient Signature *

Date *

Home Phone *

Phone where you will be staying

At the time of consultation, and pre-operatively, Dr. Thanh N. Nguyen, will perform a limited, problem - focused history and physical exam on you. It is not a complete physical check - up.

You will still need to see your regular physician for a complete check-up, or management of your existing medical problems.

Print Patient’s name *

Patient Signature *

Date *