Social History

 

Caffeine

 
 
Drinks per day:
 
 
 
 
 
 
 
 
Type(s) of caffeine:
 
 
 

Tobacco Use

 
How would you describe your cigarette smoking?
 
 
 
 
 
How many packs per day do you smoke?
How many packs per day did you smoke?
 
 
 
 
How many years have you smoked?
How many years did you smoke?
 
 
 
Do you use other tobacco products?
 
 
 

Alcohol Use

 
Do you consume alcohol?
 
 
 
 
 
Average number of drinks per week (now or in the past)?
 
 
 

Do you use street drugs?
 
 
 
 

History of physical abuse?
 
 
History of sexual abuse?
 
 

Occupation:  

Currently sexually active?
 
 
Total number of lifetime sexual partners?
 
 
 
Planning a pregnancy this year?
 
 

Current birth control method?
 
 
 
 
 
 
 
 
 
 
 
 
Monthly self breast exams?
 
 
 

Exercise

 
 
Times per week:
 
 
 
 
 
 
 
 
Type(s) of exercise:
 
 
 
 
 
 

How often do you wear a seatbelt?
 
 
 
 
 

Diagnostic Testing / Wellness

 
Have you had an abnormal pap in the last 5 years?
 
 
 

Last pap smear?
 
 
 
 
Last mammogram?
 
 
 
 
Last DXA scan (bone density)?
 
 
 
 
Last cholesterol level check?
 
 
 
 
Last colonoscopy?
 
 
 
 
Last sigmoidoscopy?
 
 
 
 
Last fecal occult blood test?
 
 
 
 
Last rubella immunity?
 
 
 
 
 

Allergies

 
Please type your initials in the provided boxes for any of the following that apply.
 
 
 No Known Allergies:
 
 
 latex:
 
 
 iodine / shellfish:
 
 
 penicillin:
 
 

Your Medical History

 
Please indicate if you have a history of any of the following.
(Mark all that apply.  if none, mark "None".)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Surgical History

 
Please indicate if you have had any of the following surgeries.
(Mark all that apply.  if none, mark "I have had no surgeries".)
 
 
 
 
 
 
 
 
 
 
 
 
 

Family Medical History

 
Please indicate if your family has a history of any of the following.
(Only include parent, grandparents, siblings, and children.)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

GYN History

 
Please indicate if you have a history of any of the following.
(Mark all that apply.  If none, mark "None".)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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 250
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.