The Gastroenterology Center of Virginia

11440 Commerce Park Dr
Suite LL-4
Reston, VA 20191
Phone: (703) 766-2600
Fax: (703)766-2604

Pre - Procedure Assessment





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ft inc


lbs






Family History of Cancer

Please state which relative(s) and at what age if known
 Who Who

Social History

       

Exercise Tolerance:

Systemic Review

Gastrointestinal

Check all that apply
  


Cardiovascular

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Respiratory/Lung

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If you have sleep apnea, have you been prescribed a CPAP or dental device? 

Urinary/Renal/Kidney

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Endocrine/Metabolic

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If you have diabetes what is:

Neurological

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Musculoskeletal

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Psychological/Psychiatric

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If you have selected substance abuse:

Gynecological

Check all that apply


Other Medical Conditions

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Please provide the best phone number(s) to reach you or the number we are permitted to leave a message regarding your procedure(s).