Tobacco Use

 
What is your smoking status?
 
 
 
 
 
 
How many cigarettes per day?
 
 
 

Alcohol Use

 
How often do you use alcohol?
 
 
 
 
 
 
 
About how much do you drink on each occasion?
 
 
 
 
 
 

Drug Use

 
 
 
 
 
 

Your Medical History

Do you have any medical history problems?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Family Medical History

Do you have any family medical conditions?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Surgical History

Do you have any surgical history?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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 491
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.