Tobacco Use

How would you describe your cigarette smoking?
 
 
 
 
 
How many years have you smoked?
How many years did you smoke?
 
How many cigarettes do you currently smoke per day?
How many cigarettes did you previously smoke per day?
 
 
 
 
Do you or have you used any other form of tobacco?
 

Alcohol Use

Do you drink alcohol?
 
 
 

Illegal / Illicit Drug Use

 
 
 
 

Are you concerned about HIV Risk?
 
 
 

Allergies

Please mark any known allergies you have.

 
 
 
 
 
 
 
 
 
 
Please describe your reaction (if any):
 
 

Your Medical History

Please indicate if YOU have a history of the following:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please list any additional conditions or diseases you have had (not shown above):
 
 
 

Family Medical History

Please indicate if YOUR FAMILY has a history of the following: ONLY include parents, grandparents, siblings, and children

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please list any family members with history of Cancer:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please list any additional pertinent family medical history (not shown above):
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 216
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.