Personal/Family History
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Provider Name
*
Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
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December
Birth Day
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Birth Year
2021
2020
2019
2018
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2016
2015
2014
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2012
2011
2010
2009
2008
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1915
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1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Personal/Family History
* Required Information
Tobacco Use
What is your smoking status?
Current (every day)
Current (some days)
In the past
Never
At what age did you begin smoking?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
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76
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78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
At what age did you quit?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
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81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
How many cigarettes do you currently smoke per day?
How many cigarettes did you previously smoke per day?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
How many cigars or pipes do you smoke per week?
None
Less than 1
1-2
3-5
6-9
10 or more
How many cans of smokeless / chewing tobacco do you use per week?
None
Less than ½
½
1
2
3 or more
Are you exposed to passive (secondhand) smoke?
Yes
No
Alcohol Use
How often do you use alcohol?
Never
1
2
3
4
5
6
7 or more
Per:
Week
Month
Year
What type(s) of alcohol do you drink?
Beer
Wine
Liquor
How many drinks do you have per occasion?
1-2
3-5
6-9
10 or more
How often do you have more than five drinks per occasion?
Never
Occasionally
Rarely
Frequently
Drug Use
None
Current
Previous
Prefer to discuss with physician
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.)
Yes
No
Prefer to discuss with physician
Habits
Caffeine
Drinks per day:
None
Occasionally
1-2
3-4
5-6
7 or more
Type(s) of caffeine:
Coffee
Tea
Soft drinks
Exercise
Times per week:
None
Occasionally
1-2
3-4
5-6
7 or more
Type(s) of exercise:
Bicycling
Running
Swimming
Walking
Aerobics
Other
How often do you wear a seatbelt?
Always
Almost always
Occasionally
Never
Sun Exposure
Occasionally
Frequently
Rarely
Past Medical History
*
Do you have any medical history problems?
Yes
No
Alcohol abuse
Anemia
Anesthetic complication
Anxiety disorder
Arthritis
Asthma
Autoimmune problems
Birth defect(s)
Bladder problems
Bleeding disease
Blood clots
Blood transfusion(s)
Bowel disease
Breast cancer
Cervical cancer
Colon cancer
Depression
Diabetes
Growth / Development disorder
Heart attack
Heart disease
Heart pain / Angina
Hepatitis A
Hepatitis B
Hepatitis C
High blood pressure
High cholesterol
HIV
Hives
Kidney disease
Liver cancer
Liver disease
Lung / Respiratory disease
Lung cancer
Mental illness
Migraines
Osteoporosis
Prostate cancer
Rectal cancer
Reflux / GERD
Seizures / Convulsions
Severe allergy
Sexually transmitted disease (STD)
Skin cancer
Stroke / CVA of the brain
Suicide attempt
Thyroid problems
Ulcer
Other significant medical illness
Family Medical History
*
Do you have any family medical conditions?
Yes
No
Unknown
Alcohol abuse
Father
Mother
Brother
Sister
Son
Daughter
Anemia
Father
Mother
Brother
Sister
Son
Daughter
Anesthetic complication
Father
Mother
Brother
Sister
Son
Daughter
Arthritis
Father
Mother
Brother
Sister
Son
Daughter
Asthma
Father
Mother
Brother
Sister
Son
Daughter
Bladder problems
Father
Mother
Brother
Sister
Son
Daughter
Bleeding disease
Father
Mother
Brother
Sister
Son
Daughter
Breast cancer
Father
Mother
Brother
Sister
Son
Daughter
Colon cancer
Father
Mother
Brother
Sister
Son
Daughter
Depression
Father
Mother
Brother
Sister
Son
Daughter
Diabetes
Father
Mother
Brother
Sister
Son
Daughter
Heart disease
Father
Mother
Brother
Sister
Son
Daughter
High blood pressure
Father
Mother
Brother
Sister
Son
Daughter
High cholesterol
Father
Mother
Brother
Sister
Son
Daughter
Kidney disease
Father
Mother
Brother
Sister
Son
Daughter
Lung / Respiratory disease
Father
Mother
Brother
Sister
Son
Daughter
Migraines
Father
Mother
Brother
Sister
Son
Daughter
Osteoporosis
Father
Mother
Brother
Sister
Son
Daughter
Rectal cancer
Father
Mother
Brother
Sister
Son
Daughter
Seizures / Convulsions
Father
Mother
Brother
Sister
Son
Daughter
Severe allergy
Father
Mother
Brother
Sister
Son
Daughter
Stroke / CVA of the brain
Father
Mother
Brother
Sister
Son
Daughter
Thyroid problems
Father
Mother
Brother
Sister
Son
Daughter
Other cancer
Father
Mother
Brother
Sister
Son
Daughter
Mother, grandmother, or sister developed heart disease before age 65.
Father, grandfather, or brother developed heart disease before age 55.
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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.