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SURGICAL SPECIALISTS OF NORTHERN VIRGINIA

Surgery Evaluation Form: Please fill out completely & print clearly.

| |Date: |

|First: |Middle: |Last: |

|Birthdate: |Age: |Height: |Weight: |

Who referred you to our practice?

Who is your primary care physician?

Reason for Visit: Duration:

Preferred Pharmacy: (Name, City and Phone Number)

List other physicians you are seeing:

Physician Name: Specialty:

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Allergies: Medications, food, environmental List Reaction:

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Medications: (List all current medications)

|Date started |Medication & Dose |Directions |Reason for Taking |Prescribed by |

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_______C.Cross _______J.Lesniewski _______V.Madey _______B.Kriss ______ J.Cook

Past Medical History: (Please check any past medical history and/or list any past medical history under other)

| Attention Deficit Disorder |Gl Dizziness/Vertigo | High cholesterol | Pneumonia |

| Alcohol Disorder/Drug addiction| Easy Bleeding | Hiatal Hernia | Psoriasis |

| Anemia | EKG (list year) | HIV Infection | Reflux |

| Arrhythmia | Emphysema | Hodgkin’s Disease | Rheumatoid Arthritis |

| Arthritis | Epilepsy | Insomnia | Seizure Disorder |

| Asthma | Esophageal Reflux | Kidney Dialysis | Sickle Cell Disease |

| Artificial joints | Fatigue | Kidney poor function | Skin Disease |

| Back Problems | Fibromyalgia | Kidney stones | Sleep Apnea |

| Blood clots in legs | Gallstones | Leukemia | STDs |

| Bronchitis | Gastrointestinal Disorder | Lung disease | Stomach Ulcers |

| Cancer (list type) | Glaucoma | Lupus | Stroke Syndrome |

| Colon polyps | Gout | Lyme Disease | Thyroid Disorders |

| Concussion | Headache | Melanoma | Tuberculosis |

| Congestive Heart Failure | Heart Attack | Migraine or Headache | Ulcer disease |

| | |(circle which one) | |

| COPD | Hemorrhoids | Osteoporosis | Urinary tract infections |

| Depression | Hepatitis or Jaundice | Pancreatitis | |

| |(circle which one) | | |

| Diabetes Mellitus | High Blood Pressure | Other (List) |

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Please list any surgeries: (Please write year of surgery and type)

|1. |6. |

|2. |7. |

|3. |8. |

|4. |9. |

|5. |10. |

Tuberculosis Symptom Screening: (Please CIRCLE appropriate answer)

|Have you had contact with anyone with active tuberculosis disease in the past year? | Yes No |

|Have you had a TB Skin Test? Yes No |Have you ever been treated for TB? Yes No |

Family History: (All medical problems, surgeries, cancer and cause of death)

| |Medical Problems |Surgeries |Cancer |Cause of death (age) |

|Mother: | | | | |

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|Father: | | | | |

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|Sisters: | | | | |

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|Brothers: | | | | |

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|Grandparents: | | | | |

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|Other: Please list any significant health issues with Aunts, Uncles, Cousins, and Children |

|Please specify who has the specific issue. |

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Social History: (Please write and/or CIRCLE the appropriate answer)

|Who lives with you? | |

|Occupation: | |

|Do you currently smoke? | Yes No Former |

|How much per day do you smoke? | Pack per day or cigarettes per day |

|What do you smoke? ( ie cigars) | |

|Do you drink alcohol? | Yes No |

|How often do you drink? | Daily Weekly Monthly Social Drinker |

|Do you currently use recreational drugs? | Yes No |

|Have you ever used recreational drugs? | Yes No |

|Please specify type and extent of use: | |

|Are you pregnant? | Yes No |

|Date of Last Menstrual cycle? | |

Review of Systems: (Please circle ALL symptoms within the past 3 months for each category below).

General/constitutional

|Fever Weight loss Change in appetite |Headaches Night sweats Recent illness |

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|Weight gain Chills Fatigue |Sleep disturbance |

ENT

|Sore throat Nasal congestion Sinus trouble |Difficulty swallowing Eye problems |

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|Dizziness Nosebleed Hearing loss | |

Cardiovascular

|Anemia Easy bruising Murmurs Edema |Blood clots Difficulty lying flat Chest Pain |

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|Ankle swelling Swelling in Hands/Feet |Heart Palpitations Shortness of Breath |

Respiratory

| Breathing problems Cough Wheezing |Coughing up Blood Shortness of Breath |

Gastrointestinal

| Gas/bloating Acid reflux |Hemorrhoids Diarrhea Indigestion |

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|Lower abdominal pain Heartburn |Nausea Vomiting Vomiting blood |

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|Upper abdominal pain Stomach problems |Rectal pain Rectal Bleeding |

Genitourinary

|Urine leakage Kidney stones Large prostate | Heavy uterine bleeding Frequent urination |

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|Erectile dysfunction |Painful urination Difficulty urinating |

Musculoskeletal

|Back pain Arthritis Neck problems Limb weakness Leg cramps Muscle aches |

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|Joint stiffness |

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Neurologic

|Seizures Tingling Numbness | Loss of consciousness Loss of balance |

Psychological

|Anxiety Depressed Mood Fear/phobia | Treatment for emotional or psychiatric disorder |

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|Auditory/visual hallucinations | |

Skin

|Hives Skin Rashes Skin Lesions | |

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BREAST PATIENTS ONLY:

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|For women with a breast condition to be evaluated: |

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|# of pregnancies: _________________________ Live Births:_________________ __________ |

|Breast Fed__________ or Bottle Fed________ _________ |

|Age when first child born: __________________________________ _____________________ |

|Age when menstrual period began: ________________________________________________ |

|Age when menstrual period stop: _____________________________ ____________________ |

|Have you used birth control pills?__Yes (Medication Name: ) No |

|Number of Years _____________________ ________ |

|Have you used Hormone Replacement Therapy? Yes (Medication Name: ) No |

|Number of Years ________________________ ______ |

|Have you used fertility drugs? Yes (Medication Name: ) No |

|When? ________________________________________ |

|Do you perform self breast exams Yes No |

|How often? __________ __________________ _____ |

Breast History:

Did you or your doctor feel any new mass(es) in your breast? Yes No Not Applicable

If yes, which breast is it in? Right Left Both

How long has it been there? ____________________________________________

Do you have any nipple discharge? Yes No Not Applicable

If yes, which nipple is it from? Right Left Both

How long has it been going on? ________________________________________

What color is it? Clear Bloody Green Yellow Milky Brown Cheesy

Does it come out by itself or only when you squeeze your nipple?

_______ By itself _______ When I squeeze

Do you have any breast pain? Yes No Not Applicable

If yes, which breast is it in? Right Left Not Applicable

Does it get worse around your periods? Yes No

When did it start? ___________________________________________________

Have you had any breast imaging since your last clinic visit? Yes No Not Applicable

If yes, what study did you have? _________________________________________

Where was it done? ___________________________________________________

If you underwent breast surgery, do you have any swelling, heaviness, tenderness, or decreased range of motion of your arm? Yes No Not Applicable

| LOUDOUN MEDICAL GROUP |Account Number |

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| PATIENT INFORMATION |

|Last Name |First Name |Middle Initial |Email: |

|Street Address |City / State |Zip Code |

|Home Telephone |Employer Telephone |Cell Telephone |Emergency Telephone/Contact |

|Social Security Number |Date of Birth (mm/dd/yy) |Sex: Male / Female |Single / Married / Divorced / |

| | | |Widowed |

|Primary Physician (PCP) |Primary Physician (PCP) Phone Number / Address |Pharmacy Name / Phone Number |

|Patient’s Employer |Employer Address |School Name / Phone Number |

|ETHNICITY (please circle one) |RACE (please circle one) |PREFERRED LANGUAGE |

|Hispanic / Latino |White Black/African American Asian |English Spanish |

|Not Hispanic or Latino Unknown |Hawaiian / Other Pacific Islander American Indian / |Or other: |

| |Alaska Native | |

| RESPONSIBLE PARTY / BILLING INFORMATION |

|Last Name (if different from |First Name (if different from |Middle Initial |

|patient) |patient) | |

|Street Address (if different from | |City / State |Zip Code |

|patient) | | | |

|Home Telephone |Cell Telephone |Employer Phone | |

|Employer |Employer Address |

|Social Security Number | | | |

| PRIMARY INSURANCE INFORMATION |

|Name of Company |Office Co-Pay $ |Insurance Telephone |

|ID / Policy Number |Group Number |

|Insurance Address (if listed on card) |City / State |Zip Code |

|Insured’s Name |Date of Birth |Relationship To Patient |Social Security Number |

|Insured’s Employer |Address / State / Zip Code |Telephone |

| SECONDARY INSURANCE INFORMATION |

|Name of Company |Insurance Telephone |

|Group Number |ID / Policy Number |

|Insurance Address (if listed on card) |City / State |Zip Code |

|Insured’s Name |Date of Birth |Relationship To Patient |Social Security Number |

|Insured’s Employer |Address / State / Zip Code |Telephone |

| PATIENT AUTHORIZATION |

|I authorize my insurance benefits to be paid directly to the physician and I am financially responsible for all charges. I hereby consent to |

|the release and re-disclosure of my medical record to enable or facilitate the collection, verification or settlement of my account for any |

|amounts due from me or any third party payor, health maintenance organization, insurer or other health benefit plan. This consent applies to |

|LMG, PC, or any of its affiliates or agents, lenders, or any third party servicer acting for LMG, PC, or any of its affiliates. |

|I agree to promptly pay for services rendered for me or the patient named above. If I fail to meet my financial commitment to LMG and it |

|becomes necessary to take action to collect my account, I agree to pay all costs and expenses incurred in the collection of my account, |

|including attorney and collection agency fees. I further agree to pay for any missed appointments of which I did not notify the medical |

|office within a reasonable amount of time. |

|I understand that if surgery is warranted, the guidelines set by the hospital and anesthesia departments require patients be seen within 30 |

|days of their surgery date. If surgery is scheduled outside of 30 days from an office appointment, I understand I will be required to return |

|to the office for an additional evaluation. Standard charges and co-payments will apply. |

|I authorize LMG to test my blood for hepatitis and/or the AIDS virus, if in their opinion an employee has suffered an exposure incident as a |

|result of my treatment, as defined by the Occupational Safety and Health Administration. |

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|SIGNATURE ______________________________________________________________________________ |

SURGICAL SPECIALISTS OF NORTHERN VIRGINIA

BREAST CARE CONSULTANTS OF NORTHERN VIRGINIA

C. BERNARD CROSS, M.D., F.A.C.S.

JAMES A. LESNIEWSKI, M.D., F.A.C.S.

SHANNON LEHR, M.D., F.A.C.S.

VIRGINIA P. MADEY, M.D., F.A.C.S.

BRITA D. KRISS, M.D., F.A.C.S.

JAMES W. COOK, M.D., F.A.C.S.

44055 RIVERSIDE PARKWAY

SUITE 246

LEESBURG, VA 20176

I HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION VIA FAX AS MAY BE DEEMED NECESSARY BY MY PHYSICIAN, WITH REGARD TO MY MEDICAL CARE.

SIGNATURE OF PATIENT DATE

ELECTIVE AUTHORIZATION

***I AGREE TO ALLOW YOU TO SPEAK TO THE FOLLOWING FAMILY MEMBERS OR ACQUAINTANCES CONCERNING MY MEDICAL CARE. YOU MAY CORRESPOND WITH THEM EITHER IN PERSON, VIA PHONE OR MAIL.

NAME RELATIONSHIP PHONE #

SIGNATURE

LOUDOUN MEDICAL GROUP

Receipt of Notice of Privacy Practices Acknowledgement

I, ___________________________________ , acknowledge receiving on

(print patient name)

______________________, a copy of Loudoun Medical Group’s Notice of Privacy Practices.

(print date)

________________________________

Patient signature or initials

FOR OFFICE USE ONLY

I attempted to obtain the patient’s signature in acknowledgement of this Receipt of Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:

|Date |Staff Initials |Reason |

| | |Refused to sign (circle if applicable) |

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| | |Other: |

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Loudoun Medical Group, PC – Notice of Patient Privacy Practices

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