DVA Medical History
Today's Date
*
/
Month
/
Day
Year
Date
Best Contact Number
*
Please enter a valid phone number.
Patient First and Last Name
*
Date of Birth
*
Height
*
in Feet and Inches
Weight
*
in pounds
How did you hear about us/Referring physician
*
Reason for Today's Visit
*
Gastrointestinal Symptom Review: Are you experiencing any of the following...?
*
YES
NO
SOMETIMES
Experiencing unexplained weight loss
Having fever or chills
Having nausea
Vomiting regularly
Having heartburn symptoms
Having difficulty swallowing
Bothered by abdominal bloating or swelling
Having abdominal pain or discomfort
Constipated
Having diarrhea
If yes, do you have diarrhea at night
Having any black, tarry stools
Seeing red blood during bowel movement
Having hemorrhoid symptoms
Have you ever had ulcers
Have you had an inflammatory disease of the small bowel or colon
Have you had gallstones
Have you had pancreatic problems
Have you had hepatitis/other liver problems
If yes, is your liver function currently normal
If constipated, how many bowel movements per week?
If having diarrhea, how many bowel movements per week?
Please Fill Out the Following Questions If You're Scheduling for a Preventative Colonoscopy
Is this your first colonoscopy?
*
Yes
No
If no, when was your last colonoscopy. Type n/a if it does not apply
*
Were polyps found?
*
Yes
No
Past History of Heart Desease
Mark if you have any of the following conditions
History of heart or lung surgery
Pacemaker/Defibrillator
Irregular Heartbeat
Issues with blood clotting or taking any blood thinners
History of endocarditis
Artificial Valve
History of Heart Attack
History of cardiac stents
If you had a heart attack, please list the date below
-
Month
-
Day
Year
Date
If you had cardiac stents placed, please list the date below
-
Month
-
Day
Year
Date
Please list your cardiologist's name and office phone #
Have you had any recent tests for your current symptoms?
When?
-
Month
-
Day
Year
Date
By whom?
Labs
CT
Colonoscopy
MRI
Ultrasound
EGD
ERCP
X-Ray
Allergies, type NKDA if there are no known allergies
*
Type of Allergy
Reactions
1
2
3
Have you ever had any surgeries? Type "N/A" if none
*
Type of Surgery
When
1
2
3
4
5
6
7
8
9
If so, did you have any problems with the following?
YES
NO
Pre procedure prep
Procedure anesthesia
During Procedure
Post procedure complications
If yes, please briefly describe the problem:
Current Medication: Type "N/A" if none
*
Name of Medication
Dose
Frequency
1
2
3
4
5
6
7
8
9
10
Have you ever been diagnosed with any health problems? (i.e. high blood pressure, anemia) or Please state the reason why you are taking any medications. Type "N/A" if none
*
1
2
3
4
5
6
7
Social History
Provide details regarding current and/or past use of the following:
YES
NO
Alcohol (beer, wine, liquor)
If yes, how often?
How many drinks?
YES
NO
I.V. or Recreational Drugs
If yes, Usage?
YES
NO
Tobacco (cigarettes, cigars, chewing tobacco)
If yes, How often?
How many?
YES
NO
Caffeine
If yes about how many cups per day?
Everyday
Some Days
Former
Never
Smoking status
Single
Married
Divorced
Widowed
Marital Status
Family History
*
Yes
No
Colon Cancer
Relation
Age of Diagnosis
*
Yes
No
Colon Polyps
Relation
Age of Diagnosis
Yes
No
Celiac Disease
Relation
Age of Diagnosis
Yes
No
Crohn’s Disease
Relation
Age of Diagnosis
Yes
No
Ulcerative Colitis
Relation
Age of Diagnosis
Yes
No
Liver disease
Relation
Age of Diagnosis
Please list any Family History of Cancer
Relation
Age of Diagnosis
Yes
No
Have you ever had any genetic testing to evaluate risk of Cancers?
Have you had any of the problems below in the past week?
General:
Fever
Chills
Appeitite change
Excessive Sweating
Fatigue
None
ENT:
Sinus congestion
Nose bleeds
Trouble swallowing
Sore throat
Hearing loss
Dental problem
Headaches
Mouth sores
Hoarseness
None
Respiratory:
Chest tightness
Shortness of breath
Wheezing
Cough
None
Cardiovascular:
Chest pain
Palpitations
Leg swelling
None
Genitourinary:
Difficulty urinating
Blood in urine
Dysuria (painful urination)
Kidney stones
Urinary incontinence
Flank pain
None
Musculoskeletal:
Joint pain
Joint swelling
Muscle weakness
Back pain
Muscle swelling
Gait problem
None
Skin:
Color change
Rash
Wound
Itching
None
Neurologic:
Dizziness
Numbness
Fainting
Headaches
Seizures
Weakness
Light-headedness
Speech difficulty
Confusion
None
Hematologic (Blood):
Swollen lymph nodes
Anemia
Bleeds/bruises easily
None
Behavioral/ Psychological:
Agitation
Decreased concentration
Difficulty sleeping
Behavior problem
Nervous/Anxious
Self injury
None
Preview PDF
Submit
Should be Empty: