Trang Vo-Nguyen, M.D.

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1 The Virginia Institute For Surgical Arts Riding Plaza, Ste. 140, Chantilly, VA Phone: / Fax: Trang Vo-Nguyen, M.D. Patient Information Requesting/Referring Physician Primary Care Physician Patient Legal Name ( First, MI, Last) Patient Social Security # Patient Date of Birth Nickname Mr. Ms. Female Single Divorced Mrs. Male Married Widowed Address Home Phone # Work Phone # City, State, Zip Cell # Pager # Religious Preference Address Employer Occupation Employer Phone # Employer Address Insured/Subscriber Information Legal Name (First, MI, Last) Relationship Date of Birth Address (if different from above) Home Phone # Social Security # City, State, Zip Work # Phone # Employer Name & Occupation Employer Address Emergency Contact Information: Relative/Friend not living with you (in case we are unable to contact you or need to contact someone regarding your case in an emergency). Contact Name Phone # Relationship to Patient Address City State, Zip Insurance Information *Call Insurance if you DO NOT know your Specialist Copay * Insurance Name Mailing address for claims Insurance Phone # Policyholder Name Policyholder Date of Birth Primary Insurance Secondary Insurance Policyholder Relationship to Patient Self Child Spouse Other Self Child Spouse Other Policyholder Employer Group # Subscriber ID # Deductible and/or Copay I understand that I am responsible for all charges. I will furnish this office with all information necessary to bill my insurance. Any balance after insurance has been paid or denied is due by me. I agree that if it becomes necessary to forward my account to a collection agency, I will also be responsible for the reasonable cost of collection, to include attorney fees. I understand that my insurance benefits and referral requirements are my responsibility and that all copayments are due at the time of service. I authorize payment of medical benefits to physician for these services and all future claims and I authorize of any medical information necessary to process this claim and all future claims. Signature (Must be a parent or guardian for children 17 and under) I acknowledge that I am in receipt of/offered the Financial Policy/HIPAA. Date

2 PATIENT HEALTH HISTORY In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible. Please fill out every item. It is important for your doctor to know that you have carefully reviewed every area of this form. This information will be entered into the computer and you are welcomed to a copy of the report if you wish. There is room to explain your answers more completely on the back of the second page. How did you hear about us? PURPOSE FOR VISIT: MEDICATIONS Please list any medications including aspirin, vitamins, over-the-counter or herbal medication? Medication Name Dose How often taken ALLERGIES Medication Name Type of Reaction Do you have environmental Allergies? Yes No Please list: Do you have food Allergies? Yes No Please list: Do you have a known allergy to Latex? Yes No Please list: PAST MEDICAL HISTORY: Have you ever been DIAGNOSED with any of the following problems? Yes No Year Comment CANCER (Please list type): Cardiovascular Do you have a pacemaker? High/Elevated cholesterol? Other Heart Problems? Respiratory Asthma COPD Tuberculosis

3 PAST MEDICAL HISTORY Continued: Yes No Year Comment Gastrointestinal Hepatitis Reflux Stomach ulcers Kidney Renal failure Mental and Emotional Depression (requiring treatment Anxiety (requiring treatment) Hematologic / Immunity Anemia HIV / AIDS Bleeding after surgery Blood transfusion Blood Clots/Pulmonary Embolus Other Not Listed Above Diabetes Problem PAST HOSPITALIZATIONS Have you ever been hospitalized for a medical problem before: Yes No If Yes please list below: Year Reason for Admission Date Physician PAST SURGICAL HISTORY Year Procedure Date Surgeon FAMILY HISTORY Please mark all that applies: Maternal Paternal Mother Father Brother Sister Grandma Grandpa Grandma Grandpa Specific Anesthesia problem CANCER (please list type under check mark) Cardiovascular: High Blood Pressure Heart Problems Respiratory: Asthma Lung Cancer Neurologic: Stroke Hematologic Bleeding / Clotting problem

4 SOCIAL HISTORY Have you ever smoked? Yes No Comments (indicate amount per day): Do you smoke now? Yes No Do you drink alcohol? Yes No Comments (indicate amount per week): Do you use any recreational drugs? Yes No Comments (indicate frequency): REVIEW OF SYSTEMS Have you RECENTLY had any of the following problems? Yes No Comment General Health Problems: What is your current height: Weight: Fever or Chills Night Sweats Weight Loss/Gain > 10 lbs / 1 month Head / Neck Problems: New Headache Vision / Eye problems Ear ache, loss of hearing Chronic sinus infections Cardiovascular Problems: Fainting / Blacking out Chest pain Irregular heartbeat / palpitations Swelling of ankles Respiratory Problems: Frequent cough Shortness of breath Wheezing Gastrointestinal Problems: Difficulty swallowing / food sticking in throat Abdominal pain Constipation Diarrhea Heartburn Nausea / Vomiting Neurologic Problems: Numbness or Tingling Seizures Urologic Problems: Blood in urine Difficulty starting urine system Burning Leaking of urine Mental and Emotional Problems: Depression (requiring treatment) Anxiety (requiring treatment) Endocrine Problems: Diabetes Thyroid disorder Other Hematologic Problems: Swollen Lymph Nodes Bruising easily Bleeding into joints Skin Problems: Itching Rash Signature: Date:

5 The Virginia Institute For Surgical Arts Riding Plaza, Ste. 140, Chantilly, VA Phone: / Fax: Trang Vo-Nguyen, M.D. CONSENT FOR PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS I,, hereby consent to the used or disclosure of my protected health information by the practice of Trang Vo-Nguyen, M.D., hereinafter referred to as ( Practice ) for the purpose of diagnosing or providing treatment to me, obtaining payment for health care bills or to conduct health care operations. I understand that diagnosis or treatment of me by Dr. Vo- Nguyen may be conditioned upon my consent as evidenced by my signature on this document. I also understand that I have the right to request restrictions as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. The practice is not required to agree to these restrictions, which I may request. However, if the practice agrees to the restrictions that I request, the restriction is binding on the practice and Dr. Vo-Nguyen. I have the right to revoke this consent, at any time, in writing, except to the extent that Dr. Vo-Nguyen or the practice has taken action in reliance on this consent. My protected health information means health information, including my demographic information, collected from me and created or received by Dr. Vo-Nguyen, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have a right to review the practice s Notice of Privacy Practices, which is available to me by request at any time, prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operation. This Notice of Privacy Practices also describes my rights and the practice s duties with respect to my protected health information. The Notice of Privacy Practices for the practice is also provided at Riding Plaza, Suite 140, Chantilly, VA As provided in our notice, the terms of our notice may change. If changes are made, I may obtain a revised Notice of Privacy Practices by calling your office and requesting a revised copy be sent in the mail or by requesting one at the time of my next appointment. Signature of Patient or Personal Representative Printed Name of Patient or Personal Representative Description of Personal Representative s Authority Date Initials:

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name *SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code