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?
 
 
 
 
 
How many packs per day do you (or did you) smoke?
 
 
 
 
How many years have you (or did you) smoke?
 
 
 
 
Do you use other tobacco products?
 
 
 
 
Are you exposed to passive (secondhand) smoke?
 
 
 

Alcohol Use

 
 
Do you consume alcohol?
 
 
 

 
Type(s):
 
 
 
 
How often do you drink?
 
Number of times:
 
 
 
 
 
 
 
 
Per:
 
 
 
 

Drug Use

 
Do you use street drugs?
 
 
 
 
 
Type(s):
 
 
 
 
 
 
 
 
 
 

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.
 
 
 

Caffeine

 
Drinks per day:
 
 
 
 
 
 
 
 
Type(s):
 
 
 
 

Exercise

 
Times per week:
 
 
 
 
 
 
 
 
type(s) of exercise:
 
 
 
 
 
 
 

Other

 
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
 
 
 
 
 
 
 
PMS
 
 
 
 
Endometriosis
 
 
 
 
Cesarean Section
 
 
 
 
Bleeding Disorder
 
 
 
 
 
 
 
Sickle Cell Disease
 
 
 
 
 
 
 
Blood Clots
 
 
 
 
 
 
 
Varicose Veins
 
 
 
 
 
 
 
High Blood Pressure
 
 
 
 
 
 
 
Heart Disease
 
 
 
 
 
 
 
Heart Attack
 
 
 
 
 
 
 
Thyroid Disease
 
 
 
 
 
 
 
Diabetes
 
 
 
 
 
 
 
Weight Disorders
 
 
 
 
 
 
 
Osteoporosis / Osteopenia
 
 
 
 
 
 
 
Tuberculosis
 
 
 
 
 
 
 
Respiratory Disease
 
 
 
 
 
 
 
Kidney Disease
 
 
 
 
 
 
 
Migraine Headaches
 
 
 
 
 
 
 
Seizures / Epilepsy
 
 
 
 
 
 
 
Stroke
 
 
 
 
 
 
 
Depression / Anxiety
 
 
 
 
 
 
 
Psychiatric Care / Hospitalization
 
 
 
 
 
 
 
Other
 
 
 
 
 
 
 

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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.