Virginia Cancer Care

19415 Deerfield Avenue 1860 Town Center Drive

Suite 107 Suite 260
Leesburg, VA 20176 Reston, VA 20190
Phone 703-729-6030 Phone 703-794-4400
Fax 703-729-1446 Fax 703-729-1446

Medical History Form

Name:_________________________________ DOB: ________________________

o MALE
o FEMALE

Reason for visit:

________________________________________________________________________
________________________________________________________________________

Referring Physician: _______________ Send records to:________________________

Please indicate if you have any current problems in any of the following areas:

o General tiredness, weight loss, decreased appetite, etc

o Fevers
o Eyes (Blurred vision, changes in vision)
o Skin (Lumps, ulcers, changing or bleeding moles)
o Ears, Mouth, Throat (decreased hearing, soreness or swallowing issues)
o Stomach (pain, indigestion, diarrhea, nausea or vomiting)
o Lungs (difficulty breathing- at rest or w/normal exertion)
o Heart/Circulation (chest pain or swollen ankles)
o Neurological (seizures, hand or foot numbness/weakness)
o Bleeding or easy bruising (if so, where_______________)
o Reproductive/Urinary (prostate or breast exam)
o Thyroid/Endocrine (excessive thirst, sweating)
o Psychiatric (guilt, lack of hope, change in sleep, unable to enjoy pleasure)
o Lymph (enlarged lymph nodes)
o Muscles/Joints/Bones (pain, aches arthritis)
o Other (______________________________)

Medical
Problems:_______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Medications currently
taken:__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Living Situation

Please circle one: SINGLE MARRIED DIVORCED WIDOWED

Lives With: _____________________________________________________________

Allergies to Foods or Medications: __________________________________________

Previous Surgical or Hospitalization

History:________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Do you smoke? YES NO If YES, for how long:__________ pks per day:___
Do you drink alcohol? YES NO If yes, how many per day/week/month:_________

Family History

Mother (age, health)______________________________________________________

Father (age, health)_______________________________________________________

Brothers (age,
health)__________________________________________________________________

Sisters (age,
health)__________________________________________________________________

Children (age,
health)__________________________________________________________________

Family History of :

Heart Disease YES NO Strokes YES NO

High Blood Pressure YES NO Diabetes YES NO
Do you have a family history of Cancer? If YES, what is the relation to you and
what type of Cancer was
diagnosed?______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Last Colonoscopy: _______________________________________________________

Last Mammogram: ______________________________________________________

Have you ever had a blood transfusion? _____________________________________

Gynecological History:

Age of Menarche______________________ Menopause____________________

Oral Contraceptive Pills

Current Use__________________________
Past Use_____________________________

Hormone Replacement Therapy

Current Use__________________________
Past Use_____________________________

Number of Pregnancies

Miscarriages_________________ Still Birth__________ Live Birth___________

Updated 5/25/2017