Tobacco Use

What is your current cigarette smoking status?
 
 
 
 
At what age did you begin smoking?
 
At what age did you quit?
 
How many cigarettes do you currently smoke per day?
How many cigarettes did you previously smoker per day?
 
How many cigars or pipes do you smoke per week?
 
 
 
 
 
 
How many cans of smokeless / chewing tobacco do you use per week?
 
 
 
 
 
 
 
Are you exposed to passive (second hand) smoke?
 
 
 

Alcohol Use

How often do you use alcohol?
 
 
 
 
 
 
 
Per:
 
 
 
What type(s) of alcohol do you drink?
 
 
 
How many drinks do you have per occasion?
 
 
 
 
How often do you have more than five drinks per occasion?
 
 
 
 
 
 

Drug Use

 
 
 
 
 

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.)
 
 
 
 

Habits

Caffeine
drinks per day:
 
 
 
 
 
type(s) of caffeine:
 
 

Exercise
times per week:
 
 
 
 
 
type(s) of exercise:
 
 
 
 
 

How often do you wear a seatbelt?
 
 
 
 

Sun Exposure
 
 
 

YOUR Medical History

Do YOU have any personal medical history?
 
 

Please indicate if YOU have a history of the following:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

FAMILY Medical History

Does your FAMILY have any medical history?
 
 
Please indicate if your FAMILY has a history of the following:     Father Mother Brother Sister Son Daughter
Abdominal Aortic Aneurysm
Alcohol Abuse
Anesthetic Complication
Asthma
Bleeding Disease
Breast Cancer
Colon Cancer
Depression
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Lung / Respiratory Disease
Peripheral Vascular Disease
Rectal Cancer
Seizures / Convulsions
Stroke / CVA of the Brain
Thyroid Problems
Other Cancer
 
 

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 823
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.