Surgical Specialists of Northern Virginia

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:

Allergies: Medications, food, environmental List Reaction:

Medications: (List all current medications)

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

______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
(circle which one) / Ulcer disease
COPD / Hemorrhoids / Osteoporosis / Urinary tract infections
Depression / Hepatitis or Jaundice (circle which one) / Pancreatitis /
Diabetes Mellitus / High Blood Pressure / Other (List)

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:
Father:
Sisters:
Brothers:
Grandparents:
Other: Please list any significant health issues with Aunts, Uncles, Cousins, and Children
Please specify who has the specific issue.

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
Weight gain Chills Fatigue / Headaches Night sweats Recent illness
Sleep disturbance

ENT

Sore throat Nasal congestion Sinus trouble
Dizziness Nosebleed Hearing loss / Difficulty swallowing Eye problems

Cardiovascular

Anemia Easy bruising Murmurs Edema
Ankle swelling Swelling in Hands/Feet / Blood clots Difficulty lying flat Chest Pain
Heart Palpitations Shortness of Breath

Respiratory

Breathing problems Cough Wheezing / Coughing up Blood Shortness of Breath

Gastrointestinal

Gas/bloating Acid reflux
Lower abdominal pain Heartburn
Upper abdominal pain Stomach problems / Hemorrhoids Diarrhea Indigestion
Nausea Vomiting Vomiting blood
Rectal pain Rectal Bleeding

Genitourinary

Urine leakage Kidney stones Large prostate
Erectile dysfunction / Heavy uterine bleeding Frequent urination
Painful urination Difficulty urinating

Musculoskeletal

Back pain Arthritis Neck problems Limb weakness Leg cramps Muscle aches
Joint stiffness

Neurologic

Seizures Tingling Numbness / Loss of consciousness Loss of balance

Psychological

Anxiety Depressed Mood Fear/phobia
Auditory/visual hallucinations / Treatment for emotional or psychiatric disorder

Skin

Hives Skin Rashes Skin Lesions

BREAST PATIENTS ONLY:

For women with a breast condition to be evaluated:
# 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
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)
Hispanic / Latino
Not Hispanic or Latino Unknown / RACE (please circle one)
White Black/African American Asian
Hawaiian / Other Pacific Islander American Indian / Alaska Native / PREFERRED LANGUAGE
English Spanish
Or other:
RESPONSIBLE PARTY / BILLING INFORMATION
Last Name (if different from patient) / First Name (if different from patient) / Middle Initial
Street Address (if different from patient) / City / State / Zip Code
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.
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.

NAMERELATIONSHIPPHONE #

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)
Other:

Loudoun Medical Group, PC – Notice of Patient Privacy Practices

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