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

Women's History

* Required Information
Tobacco Use
What is your smoking status?
How many packs per day do you smoke? How many packs per day did you smoke?
How many years have you smoked? How many years did you smoke?
Do you use other tobacco products?
Are you exposed to passive (secondhand) smoke?
Alcohol Use
Do you consume alcohol?
How often do you drink?
Number of times:
Drug Use
Do you use street drugs?
Risk Factors
Please answer yes or no if you or your partner have had any of the following: IV drug use, more than one sexual partner, unprotected sexual contact, contact with contaminated injection equipment, multiple blood transfusions, HIV or Hepatitis B.
Drinks per day:
Times per week:
Type(s) of exercise:
How often do you wear a seatbelt?
Sun exposure
Do you feel safe at home?
In the past year, have you been hit, punched, kicked or slapped by anyone?
Surgical History
*Do you have any surgical history?
Past Medical History
*Do you have any medical history problems?
Menstrual History
Menstrual period:
Length of flow (on average):
Cycle regularity (from 1st day of period to start of next period):
Current contraception (mark all that apply):
Prior contraception (mark all that apply):
Sexual History
Have you ever had sex?
Did you begin having sex before the age of 18?
Are you currently sexually active?
Are you planning a pregnancy this year?
Pregnancy History
Number of pregnancies (include current)
Number of live births
Number of stillbirths
Number of vaginal deliveries
Number of cesarean sections
Number of miscarriages
Number of abortions
Number of ectopics (tubal pregnancy)
Have you had any complications?
Family Medical History
*Do you have a family history of illnesses?
Breast cancer
Lung cancer
Uterine cancer
Other cancer
Cesarean section
Bleeding disorder
Sickle cell disease
Blood clots
Varicose veins
High blood pressure
Heart disease
Heart attack
Thyroid disease
Weight disorders
Osteoporosis / Osteopenia
Respiratory disease
Kidney disease
Migraine headaches
Seizures / Epilepsy
Depression / Anxiety
Psychiatric care / Hospitalization

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 845
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.