Patient Information

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

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
 
 
 
 
 
 
 
 

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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.