*Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.
 
 

Personal/Family History

* Required Information
Tobacco Use
What is your smoking status?
At what age did you begin smoking?
At what age did you quit?
How many cigarettes do you currently smoke per day? How many cigarettes did you previously smoke per day?
How many cigars or pipes do you smoke per week?
How many cans of smokeless / chewing tobacco do you use per week?
Are you exposed to passive (secondhand) smoke?
Alcohol Use
How often do you use alcohol?
Per:
What type(s) of alcohol do you drink?
How many drinks do you have per occasion?
How often do you have more than five drinks per occasion?
Drug Use
HIV High Risk Behavior
(HIV Risk Factors: IV drug use, more than one sexual partner, sex with a prostitute, unprotected sexual contact, contact with contaminated injection equipment.)
Habits
Caffeine
Drinks per day:
Type(s) of caffeine:
Exercise
Times per week:
Type(s) of exercise:
How often do you wear a seatbelt?
Sun Exposure
Past Medical History
*Do you have any medical history problems?
Family Medical History
*Do you have any family medical conditions?
Alcohol abuse
Anemia
Anesthetic complication
Arthritis
Asthma
Bladder problems
Bleeding disease
Breast cancer
Colon cancer
Depression
Diabetes
Heart disease
High blood pressure
High cholesterol
Kidney disease
Lung / Respiratory disease
Migraines
Osteoporosis
Rectal cancer
Seizures / Convulsions
Severe allergy
Stroke / CVA of the brain
Thyroid problems
Other cancer

IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
 
Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 860
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.