If you need further assistance, please call your Executive Health Coordinator at 703.717.4700.
By completing this form you also acknowledge that you have been provided with a copy of Virginia Hospital Center's Privacy Notice and that you understand that the information you provide will only be used for treatment, payment and Hospital operations as described in the Notice and in accordance with applicable federal and state laws and regulations.
Privacy Policy
Patient Information
Gender Male Female AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Are You Employed? Yes No Retired If yes, what is your occupation?
Have you traveled outside of the USA and/or Canada in the past five years? Yes No
Family Information
Please check illnesses that have occurred in any of your blood relatives:
Present marriage? (years) Previous marriage(s)? (years)
Please list present age or age at death for all family members:
Personal History
What type of excercise or physical activities do you perform and how frequently? Please specify
Have you had any serious injuries, broken bones, etc.? Yes No If yes, please specify
Have you ever had an allergic reaction to any medications? Yes No If yes, list medications and describe reactions
Have you ever had an allergic reaction to X-ray contrast dye? Yes No If yes, please describe
Have you ever had a latex allergy? Yes No If yes, please describe
Have you ever had a tape allergy? Yes No If yes, please describe
Please list all medications you are presently tasking along with the dosage (mg) and frequency (once, twice, etc., per day) Please specify
Have you taken cortisone-type drugs? Yes No
Have you ever had your blood products transfused? Yes No If yes, when? (mm/dd/yyyy)
When was your most recent proctoscopic, sigmoidoscopic, barium enema, or colonoscopic exam ? (mm/dd/yyyy)
Personal History (cont.)
When was your last PAP? (mm/dd/yyyy) What were the results? Normal Abnormal
When was your last menstrual period? (mm/dd/yyyy)
When was your last mammogram? (mm/dd/yyyy)
How would you describe your periods? (check all that apply) Regular Irregular Pain Cramps
How many pregnancies have you had (if any)? Have you ever had a miscarriage? If yes, how many? What form of birth control are you using?
Summary
If you would like a summary of your medical findings sent to your primary care physician, please complete the following AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Why are you interested in Executive Health? Please specify
How did you hear about us? Please specify