GENERAL HEALTH

Compared to other people your age, how would you describe your overall health?
 
 
 
 
 
 
In the past 12 months, how many times have you been seen as a patient in a doctor's office, urgent care, clinic, emergency room, or hospital?
 
 
 
 
In the past 12 months, how many days did you miss from work/school because you were sick?
 
 
 
 
How many prescription medications are you currently taking?
 
 
 
 
When did you have your last routine physical checkup?
 
 
 
 
Who is your preferred provider? If none, please enter "NONE".
Name:
Do you have any chronic health problems not previously listed (in the forms you have already filled out)?
 
 
 
(please list):
Have you had any major surgeries, heart procedures, or other procedures not previously listed (in the forms you have already filled out)?
 
 
 
(please list):
 

PREVENTATIVE

Did you receive the flu vaccine last year?
 
 
When did you have your last vision exam?
 
 
 
 
 
 
When did you have your last checkup with your dentist?
 
 
 
 
 
 
How often do you brush your teeth?
 
 
 
 
When did you have your last colonoscopy or sigmoidoscopy?
 
 
 
 
When did you have your last pap smear test or pelvic exam?
 
 
 
 
 
 
When did you have your last mammogram (breast x-ray)?
 
 
 
 
 
 
When did you have your last prostate-specific antigen (PSA) test?
 
 
 
 
 
 
 

NUTRITION

A serving of VEGETABLES is: 1 cup of raw or cooked vegetables, 1 cup of vegetable juice, or 2 cups of leafy salad greens. Fresh, frozen, and canned vegetables all count.
How many servings of vegetables do you eat per day?
A serving of FRUIT is: 1 cup of raw or cooked fruit, 100% fruit juice, or 1/2 cup dried fruit. Fruits dried, frozen, and canned (in water or 100% juice), as well as fresh fruit all count.
How many servings of fruit do you eat per day?
A serving of GRAINS is: 1 slice of bread; 1/2 cup cooked rice, cereal, or pasta; 1 ounce of ready-to-eat cereal. Grains are foods that contain fiber. Choose whole grain products such as whole-wheat bread, brown rice, or oatmeal.
How many servings of grains do you eat per day?
How many servings of high-fiber, whole-grains do you eat per day?
A serving of DAIRY is: 1 cup of milk, yogurt, or fortified soymilk; 1.5 ounces of natural or 2 ounces of processed cheese. Dairy has calcium and other essential nutrients. Chose skim (fat free) or 1% (low fat) dairy products.
How many servings of dairy do you eat per day?
How many servings of low-fat dairy do you eat per day?
A serving of PROTEIN is: 1 ounce of meat, poultry, or fish; 1 egg; 1 Tbsp peanut butter; 1/2 ounce nuts or seeds; 1/4 cup beans or peas. Choose lean meats or ground beef that is at least 90% lean.
How many servings of protein foods do you eat per day?
How many servings of lean protein foods do you eat per day?
Foods high in UNHEALTHY FATS include red or fatty meats, fried foods, snack foods, bakery goods, or high-fat dairy products.
How many servings of unhealthy fats do you eat per day?
 

EXERCISE

Cardiovascular exercises include jogging, cardio machines, aerobics, brisk walking, swimming, biking, or any other such exercise.
How many minutes per session do you do cardiovascular exercise?
 
 
 
 
 
 
 
Strength building exercises include weightlifting, push-ups, sit-ups, yoga, pilates, or other such exercises.
How many days of the week do you do strength-building exercises?
 
 
 
 
 
 
 
How many minutes per session do you do strength-building exercises?
 
 
 
 
 
 
 
 

SLEEP PATTERN

On a typical night, how many hours do you sleep?
 
 
 
 
 
 
Are you tired during the day even after a full night of sleep?
 
 
Has anyone told you that you snore?
 
 
Has anyone told you that you stop breathing when you sleep?
 
 
 

SAFETY

To use proper form to lift objects, you should keep your back straight, bend your knees, keep your head up, and use your legs to do the lifting.
When lifting objects, do you lift them properly?
 
 
Repetitive motions with your arms and hands include typing, grasping, or assembly line tasks for more than 1 hour a day.
Do you engage in repetitive motions?
 
 
How often do you wear a helmet while riding a motorcycle, bicycle, horse, all-terrain vehicle, or any other such activity?
 
 
 
 
 
How often do you wear protective clothing or sunscreen when you are in the sun?
 
 
 
 
 
 

LIMITATIONS

Do you have an impairment or health problem that limits your activities in any way?
 
 
Do you need help from other persons with your personal care needs because of any impairment or health problem? (Personal care needs include eating, bathing, dressing, or getting around the house.)
 
 
Do you need help from other persons in handling your routine needs? (Routine needs include everyday household chores, doing necessary business, shopping, or getting around for other purposes.)
 
 
 

HEALTHY CHANGES

Are you interested in improving your health? Choose one.
 
 
 
 
 
 
Are you interested in improving your diet? Choose one.
 
 
 
 
 
 
Are you interested in increasing your level of cardiovascular or strength building exercises? Choose one.
 
 
 
 
 
 
 

WORK PERFORMANCE

In the last two weeks, has your physical or emotional health made it DIFFICULT for you to:
Get going easily at the beginning of the workday
 
 
Start on your job as soon as you arrive at work
 
 
Concentrate on your work
 
 
Speak with people in-person, in meetings, or on the phone
 
 
Sit, stand, or stay in one position for longer than 15 minutes while working
 
 
Repeat the same motions over and over again while working
 
 
Handle your workload
 
 
Finish your work on time
 
 
 

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 1714
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.