Patient Information

*Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.

Women's History

* Required Information

Social History

*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)?
Drug Use
*Do you use street drugs?
*History of physical abuse?
*History of sexual abuse?
Sexual Activity
*Currently sexually active?
*Total number of lifetime sexual partners?
*Planning a pregnancy this year?
Birth Control
*Current birth control method?
*Monthly self breast exams?
*Times per week:
*Type(s) of exercise:
Seatbelt Use
*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?


*Please type your initials in the provided boxes for any of the following that apply.
No Known Allergies:
Iodine / Shellfish:

*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.