Social History

 
Smoking:
 
 
 
 
Secondhand smoke exposure:
 
 

Alcohol:
 
 
 
 

Recreational drugs:
 
 
 
 
 

Past Medical History

 
Please indicate if you have had any of the following.
Mark all that apply.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Cancer

 
 
 
 
 
 
 
 
 
 

Surgical History

 
Please indicate if you have had any of the following surgeries.
Mark all that apply.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Family Medical History

 
Please indicate which family members have had these illnesses:
 
 
 
 
   Mother   Father   Sister   Brother   Daughter   Son 
bleeding disorder  
colon polyps  
Crohn's disease  
diabetes  
genetic / inheritable disease(s)  
heart disease  
problems with anesthesia  
sickle cell disease  
stroke  
ulcerative colitis  
breast cancer  
colon cancer  
lung cancer  
melanoma / skin cancer  
ovarian cancer        
pancreatic cancer  
prostate cancer        
thyroid cancer  
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 854
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.