Who is filling out this form?
 
 
 
 
please specify:
 

GENERAL HEALTH

Compared to other people of the same age, how would you describe the patient's overall health?
 
 
 
 
 
 
In the last year, how many times has the patient been seen in a doctor's office, urgent care, clinic, emergency room, or hospital?
 
 
 
 
 
How many prescription medications is the patient currently taking?
 
 
 
 
 
In the past year, how many days did the patient miss from work/school because he/she was sick?
 
 
 
 
 
When did the patient have their last routine physical checkup or well child visit?
 
 
 
 
 
Who is the patient's preferred provider? If none, please enter "NONE".
 
 

PREVENTIVE

Did the patient receive the flu vaccine last year?
 
 
 
When did the patient have his/her last vision exam?
 
 
 
 
 
 
When did the patient have his/her last checkup with a dentist?
 
 
 
 
 
 
How often does the patient brush his/her teeth?
 
 
 
 
 
 

NUTRITION

How often does the patient eat breakfast?
 
 
 
 
 
How often does the patient eat fruits and vegetables?
 
 
 
 
 
 
How often does the patient drink milk?
 
 
 
 
 
 
How often does the patient eat dairy products such as cheese or yogurt?
 
 
 
 
 
 
How often does the patient eat high-fiber foods such as whole wheat bread, rice, pasta, or cereal?
 
 
 
 
 
 
How often does the patient snack on sugary foods such as cake, cookies, candy, or soda?
 
 
 
 
 
 
How often does the patient eat fast food such as burgers, pizza, fried chicken, or french fries?
 
 
 
 
 
 
 

EXERCISE

How often does the patient go to physical education class or play a team sport per week?
 
 
 
 
 
How often does the patient walk, run, or play actively for an hour or more per week?
 
 
 
 
 
Describe how long the patient sits watching television, playing video games, using the computer, or talking on the phone daily:
 
 
 
 
 
 

SAFETY

How often does the patient wear a safety belt when driving or riding in a car?
 
 
 
 
 
How often does the patient wear a helmet while riding a motorcycle, bicycle, horse, all-terrain vehicle, skateboard, skates, or any other such activity?
 
 
 
 
 
 
How often does the patient wear protective clothing or sunscreen while in the sun?
 
 
 
 
 
 
 

VIOLENCE

When away from home, has the patient ever been physically threatened or hurt?
 
 
 
 
 
When away from home, has the patient ever been in a serious fight?
 
 
 
 
 
Has the patient ever carried a weapon, such as a gun, knife or club?
 
 
 
 
 
 

EMOTIONAL HEALTH

Describe how happy the patient is on most days:
 
 
 
 
 
 
Does the patient have someone who might help him/her with a problem, such as a friend, family member, or teacher?
 
 
 
 
 
Has the patient had any recent problems, such as someone close dying, a relationship ending, or trouble at school or home?
 
 
 
 
 
Has the patient had any recent problems, such as being laughed at, called hurtful names, or being excluded from a group away from home?
 
 
 
 
 
 

HABITS/LIFESTYLE

Does the patient have trouble sleeping at night?
 
 
 
 
 
How often does the patient breathe cigarette or tobacco smoke?
 
 
 
 
 
Does the patient have pets?
 
 
 
How often has the patient attended daycare/school?
 
 
 
 
 
 

HEALTH HISTORY

Does the patient have any chronic health problems?
 
 
 
please list
 
 
Has the patient had any major surgeries or procedures?
 
 
 
please list
 
 
As far as you know, are the patient's immunizations up-to-date?
 
 
 

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 727
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.