* = Required Information
PATIENT INFORMATION
Yes No
F M
S M D W
If patient is under 18 years old: RESPONSIBLE PARTY
F M
For Workers’ Comp. case only: EMPLOYMENT INFORMATION
If Applicable: PRIMARY INSURANCE INFORMATION
Yes No
PERSON TO NOTIFY IN EMERGENCY:
I acknowledge that I am responsible for all the charges for services rendered to me.
PATIENT MEDICAL HISTORY
Good Fair Poor
PAST MEDICAL HISTORY
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
HAVE YOU HAD ANY ILLNESSES WITH THE FOLLOWING:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
HAVE YOU EVER HAD ANY OF THE FOLLOWING:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
FAMILY HISTORY (Has any relative had):
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

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.
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