DVA Medical History-2021

DVA Medical History
Today's Date*

MonthDayYear
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?*

YesNo
If no, when was your last colonoscopy. Type n/a if it does not apply*
Were polyps found?*

YesNo
Past History of Heart Desease
Mark if you have any of the following conditions

History of heart or lung surgeryPacemaker/DefibrillatorIrregular HeartbeatIssues with blood clotting or taking any blood thinnersHistory of endocarditisArtificial ValveHistory of Heart AttackHistory of cardiac stents
If you had a heart attack, please list the date below

MonthDayYear
Date
If you had cardiac stents placed, please list the date below

MonthDayYear
Date
Please list your cardiologist's name and office phone #
Have you had any recent tests for your current symptoms?
When?

MonthDayYear
Date
By whom?
LabsCTColonoscopyMRIUltrasoundEGDERCPX-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
Alcohol (beer, wine, liquor)

	YES	NO
I.V. or Recreational Drugs

	YES	NO
Tobacco (cigarettes, cigars, chewing tobacco)

If yes, How often?
How many?
YES NO

Caffeine
If yes about how many cups per day?

	YES	NO
Caffeine

	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
Colon Cancer

	Yes	No
Colon Polyps

	Yes	No
Celiac Disease

	Yes	No
Crohn’s Disease

	Yes	No
Ulcerative Colitis

	Yes	No
Liver disease

	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:

FeverChillsAppeitite changeExcessive SweatingFatigueNone
ENT:

Sinus congestionNose bleedsTrouble swallowingSore throatHearing lossDental problemHeadachesMouth soresHoarsenessNone
Respiratory:

Chest tightnessShortness of breathWheezingCoughNone
Cardiovascular:

Chest painPalpitationsLeg swellingNone
Genitourinary:

Difficulty urinatingBlood in urineDysuria (painful urination)Kidney stonesUrinary incontinenceFlank painNone
Musculoskeletal:

Joint painJoint swellingMuscle weaknessBack painMuscle swellingGait problemNone
Skin:

Color changeRashWoundItchingNone
Neurologic:

DizzinessNumbnessFaintingHeadachesSeizuresWeaknessLight-headednessSpeech difficultyConfusionNone
Hematologic (Blood):

Swollen lymph nodesAnemiaBleeds/bruises easilyNone
Behavioral/ Psychological:

AgitationDecreased concentrationDifficulty sleepingBehavior problemNervous/AnxiousSelf injuryNone
Should be Empty:

DVA Medical History

Please Fill Out the Following Questions If You're Scheduling for a Preventative Colonoscopy

Past History of Heart Desease

Have you had any recent tests for your current symptoms?

Social History

Family History

Have you had any of the problems below in the past week?