Patient Registration Forms


Patient Interview Form

Page 1 of 7

Patient Information
Email

Please check one as your preferred email for communications

Race

Select one or more

White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Unknown
Patient declines to specify
Prohibited by state law
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Patient declines to specify
Prohibited by state law
Sex
Male
Female
Other
Preferred Language
English
Patient declines to specify
Contact Preference
Letter
Email
Patient declines to specify

Page 2 of 7

Pharmacy
Allergies
Patient has no known allergies
Patient has known drug allergies
Current Medications
None
Immunizations
None
Flu vaccine
Hep A
Hep B
Pneumovax
TB Skin Test
Diagnostic Studies/Tests
None
Colonoscopy
EGD
CT Abdomen/Pelvis
MRI Abdomen/Pelvis
ERCP
Previous Procedures
None
Gallbladder Removed
Appendectomy
Colon Resection
Small Bowel Resection
Exploratory Laparoscopy
Gastric Bypass
Gastric Lap Band
Hemorrhodectomy
Hemorrhoid Banding
Abdominoplasty
Hysterectomy Abdominal
Bilateral Tubal Ligation (BTL)
Mastectomy R Breast
Pacemaker Insertion
Defibrillator Placement
Coronary Artery Bypass Graft (CABG)
Abdominal Aortic Aneurysm (AAA) Repair
Heart Valve Replacement
Cardiac Cath with Stent Placement
Joint Replacement
Back Surgery
Fibromyalgia
Other:
Other:

Page 3 of 7

Past or Present Medical Conditions
None
Gastroenterology / Hepatology

Colon Polyp History
Colon Cancer
Irritable Bowel Syndrome
Diverticulitis
Crohn's Disease
Ulcerative Colitis
Gastroesophageal Reflux Disease (GERO)
Barrett's Esophagus
Ulcer Disease
Hepatitis B
Hepatitis C

Fatty Liver

Cirrhosis
Celiac Disease
Bowel Obstruction
Pancreatitis
Anemia
Other:
Other:
Cardiology

Coronary Artery Disease
Congestive Heart Failure
Heart Attack
High Blood Pressure
Atrial Fibrillation
Vascular Disease
High Cholesterol
Stroke
Transient Ischemic Attack
Valvular Heart Disease
Pacemaker
Coronary Artery Stents
Other:
Other:
Pulmonology

C.O.P.D.
Asthma
Sleep Apnea
Blood Clots (leg)
Blood Clots (lung)
Wheezing
Other:
Other:
Other

Anxiety Disorder
Arthritis
Bipolar Disorder
Body Piercings
Breast Cancer
Current Pregnancy
Depression
Diabetes Mellitus, Insulin Dependent (Type 1)
Diabetes Mellitus, NonInsulin Dependent (Type 2)
Fibrositis / Fibromyalgia
Gout
HIV Exposure
HIV Infection
Hypothyroidism
Kidney Disease
Kidney Stones
Lung Cancer
Ovarian Cancer
Prostate Cancer
Skin Cancer
Seizures
Tattoos

Page 4 of 7

Social History
Occupation:
Number of Children:
Marital Status

Single
Married
Divorced
Separated
Widowed
Civil Union
Unknown
Other
Alcohol

None
Occasionally
Daily
Caffeine

None
Occasionally
Daily
Tobacco Smoking Status

Current Every Day Smoker
Current Some Day Smoker
Former Smoker
Never Smoker
Smoker, Current Status Unknown
Light Tobacco Smoker
Heavy Tobacco Smoker
Unknown If Ever Smoked
Type
Started
Quit
Quantity
Frequency
Cigarettes

Cigar

Chewing Tobacco

Drug Use

None
Type
Quantity
Number
Frequency
IV or Intranasal Drugs

Recreational

Exercise

None
Regular Exercise
Occasional Exercise

Page 5 of 7

Family Medical History
No Knowledge of Family History:
No Family History of

Celiac Sprue
Colon Cancer
Colon Polyps
Crohn's Disease
Liver Disease
Stomach Cancer
Ulcerative Colitis / IBD

Health Status

Mother

Father

Sister

Brother

Grandmother

Grandfather

Age
Healthy
Ill
Seriously Ill
Disabled
In Remission
Alive
Deceased
At Age

Cause of Death

Diagnoses

Mother

Father

Sister

Brother

Grandmother

Grandfather

Celiac Disease
Colon Cancer
Colon Polyps
Crohn's Disease
Gallbladder Disease
Liver Disease
Ulcerative Colitis
Other

Page 6 of 7

Review Of Systems
Allergic / Lmmunologic
None

Y

N

HIV Exposure
Persistent Infections
Strong Allergic Reactions or Urticaria
Cardiovascular
None

Y

N

Chest Pain
Dyspnea with Exercise
Irregular Heart Beat
Orthopnea
Palpitations
Peripheral Edema
Syncope
Constitutional
None

Y

N

Fatigue
Fever
Loss of Appetite
Malaise
Sweats
Weight Gain
Weight Loss
ENMT
None

Y

N

Difficulty Swallowing
Dizziness
Ear Pain
Nasal Obstruction
Nose Bleeds
Sore Throat
Hearing Loss
Endocrine
None

Y

N

Excessive Thirst
Hair Loss
Heat Intolerance
Eyes
None

Y

N

Double Vision
Loss of Vision
Photophobia
Gastrointestinal
None

Y

N

Abdominal Pain
Abdominal Swelling
Change in Bowel Habits
Constipation
Diarrhea
Gas
Heartburn
Jaundice
Nausea
Rectal Bleeding
Stomach Cramps
Vomiting
Difficulty Swallowing
Genitourinary
None

Y

N

Dark Urine
Decrease in Urine Flow
Dysuria
Frequent Urinary Infections
Frequent Urination
Hematuria
Impotence
Nocturia
Urethral Discharge or Incontinence
Hematologic / Lymphatic
None

Y

N

Bleeding Gums or Palpable Lymph Nodes
Easy Bruising
Prolonged Bleeding
lntegumentary
None

Y

N

Allergies
Dryness
Hives
Itching
Jaundice
Lesions
Rashes
Musculoskeletal
None

Y

N

Allergies
Back Pain
Gout
Joint Deformity
Joint Pain
Muscle Weakness
Stiffness
Neurological
None

Y

N

Dizziness
Fainting
Frequent Headaches
Migraine
Numbness or Tingling
Seizures
Tremors
Vertigo
Memory Loss
Psychiatric
None

Y

N

Anxiety
Depression
Difficulty Sleeping
Hallucinations
Nervousness
Panic Attacks
Paranoia
Respiratory
None

Y

N

Asthma
Cough
Dyspnea
Excessive Sputum
Coughing up Blood
Shortness of Breath with Exercise
Wheezing

Page 7 of 7

Consent to Import Medication History

I consent to obtaining a history of my medications pure ased at pharmacies.

Yes
No
Reminder Preference

I would like to receive preventive care and follow up care reminders.

Yes
No
Reviewed with
Patient
Parent
Guardian
Not Present
Who is your Primary Care Physician?
What health insurance company is your coverage with?
Do you have an Advanced Directive ?
Yes
No

An Advance Directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.

Have you had a pneumococcal (pneumonia) vaccine ?
Yes
No
Signature

About us


We would like to welcome you to the Gastroenterology Center of Northern Virginia, Ltd. We appreciate the opportunity to participate in your care. It is our sincere desire to provide you with the highest quality and most comprehensive services in the diagnosis, treatment and management of various digestive conditions.

Arlington Address

1715 North George Mason Drive, Suite 204 Arlington, VA 22205
(adjacent to the Virginia Hospital Center, Zone C,
Parking C )
Phone: (703) 522-7476
Fax: (703) 528-4209
Office hours:
Monday – Thursday 8:30 am – 5:00 pm
Friday 8:30 am – 4:30 pm

Annandale Address

3299 Woodburn Road, Suite 220 Annandale, VA 22003
(second building in the Woodburn Medical complex)
Phone: (703) 560-6106
Fax: (703) 204-1968
Office hours:
Monday - Thursday 8:30 am – 5:00 pm
Friday 8:30 am – 4:30 pm
Copyright - 2019 Gastroenterology Center of Northern Virginia. All rights reserved.