Personal / Family History
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Provider Name
*
Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Personal / Family History
Do you have children?
Yes
No
How many children do you have?
Occupation:
Allergy History
Do you have any allergy history?
Yes
No
Aspirin
Codeine
Erythromycin
NSAIDs
Penicillins
Sulfa drugs
Tetracyclines
Cephalosporins - Kelflex/Cephalexin
Other
Past Medical History
Do you have any past medical history?
Yes
No
Alcohol Abuse
Allergies
Anemia
Anesthetic Complication
Heart Pain / Angina
Anxiety Disorder
Arthritis
Asthma
Autoimmune Problems
Birth Defect(s)
Bladder Problems
Bleeding Disease
Blood Clots
Bowel Disease
Breast Cancer
Cervical Cancer
Colon Cancer
Stroke / CVA of the Brain
Seizures / Convulsions
Depression
Diabetes
Reflux / GERD
Growth / Development Disorder
Heart Disease
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
HIV
Hives
High Cholesterol
Kidney Disease
Liver Cancer
Liver Disease
Lung Cancer
Mental Illness
Migraines
Heart Attack
Osteoporosis
Prostate Cancer
Lung / Respiratory Disease
Rectal Cancer
Sexually Transmitted Disease (STD)
Skin Cancer
Suicide Attempt
Thyroid Problems
Blood Transfusion(s)
Ulcer
Other Disease, Cancer, or Significant Medical Illness
Family Medical History
Do you have any family medical history?
Yes
No
Unknown
Alcohol Abuse
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Anemia
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Anesthetic Complication
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Anxiety
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Arthritis
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Asthma
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Bladder Problems
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Bleeding Disease
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Breast Cancer
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Colon Cancer
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Depression
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Diabetes
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Heart Disease
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
High Blood Pressure
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
High Cholesterol
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Kidney Disease
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Lung / Respiratory Disease
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Migraines
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Osteoporosis
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Rectal Cancer
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Seizures / Convulsions
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Severe Allergy
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Stroke / CVA of the Brain
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Thyroid Problems
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Other Cancer
Father
Mother
Brother
Sister
Son
Daughter
Grandfather Mother's side
Grandmother Mother's side
Grandfather Father's side
Grandmother Father's side
Mother, Grandmother, or Sister developed Heart Disease before age 65.
Father, Grandfather, or Brother developed Heart Disease before age 55.
Surgical History
Do you have any surgical history?
Yes
No
Anal Fissure Repair
Low Back Disc Surgery
Tonsillectomy
Deviated Nose Septum
Appendectomy
Neck Disc Surgery
Ulcer Surgery
Tubal Ligation
Hemorrhoidectomy
Sinus Surgery
Vasectomy
Prostate Surgery
TURP
Removal
Gallbladder Surgery
Open
Laparoscopic
Colon Polyp Removal
Open
Colonoscopy
Colon Removal
Partial
Complete
Hysterectomy (due to cancer)
Partial
Complete
Hysterectomy (not due to cancer)
Partial
Complete
Spinal Fusion
Neck
Lower Back
Spinal Decompression
Neck
Lower Back
Dilation and Curettage (D&C)
Single
Multiple
Lung Surgery
Left
Right
Both
Kidney Removal
Left
Right
Both
Cataract Surgery
Left
Right
Both
Breast Cancer Lump Removal
Left
Right
Both
Mastectomy
Left
Right
Both
Breast Reconstruction
Left
Right
Both
Breast Reduction
Left
Right
Both
Ovary Removal
Left
Right
Both
Carpal Tunnel Surgery
Left
Right
Both
Rotator Cuff Repair
Left
Right
Both
Arthroscopic Shoulder Surgery
Left
Right
Both
Hip Fracture & Surgery
Left
Right
Both
Total Hip Replacement
Left
Right
Both
Total Knee Replacement
Left
Right
Both
Arthroscopic Knee Surgery
Left
Right
Both
Foot Surgery
Left
Right
Both
Varicose Vein Procedure
Left
Right
Both
Mastoidectomy
Left
Right
Both
Thyroid Removal
Left
Right
Total
Partial
Breast Biopsy
Left
Right
Both
Multiple times
Carotid Artery Surgery
Left
Right
Both
Multiple times
Open Inguinal Hernia Surgery
Left
Right
Both
Multiple times
Laparoscopic Inguinal Hernia Surgery
Left
Right
Both
Multiple times
Caesarean Section
1
2
3 or more
Heart Valve Replacement
Mitral
Aortic
Tricuspid
Unknown Valve
Heart Bypass Surgery
1 vessel
2 vessels
3 vessels
4 or more vessels
Unknown number of vessels
Social History
Tobacco Use
What is your smoking history?
Never smoked cigarettes
Former cigarette smoker
Current cigarette smoker
How many years did you smoke?
.5
1
3
5
7
10
15
20
25
30
What was your daily use (i.e. number of cigarettes per day)?
5
10
15
20
30
40
50
60
What is your daily use (i.e. number of cigarettes per day)?
5
10
15
20
30
40
50
60
How many years have you been smoking?
.5
1
3
5
7
10
15
20
25
30
Do you use e-cigarettes/vape?
Yes
No
Alcohol Use
How often do you use alcohol?
Never
1
2
3
4
5
6
7 or more
Per:
Week
Month
Year
What type(s) of alcohol do you drink?
Beer
Wine
Liquor
How many drinks do you have per occasion?
1-2
3-5
6-9
10 or more
How often do you have more than five drinks per occasion?
Never
Occasionally
Rarely
Frequently
Drug Use
None
Current
Previous
Prefer to discuss with physician
Habits
Caffeine
Type(s) of caffeine:
Coffee
Tea
Soft drinks
Drinks per day:
0
Occasionally
1-2
3-4
5-6
7 or more
Exercise
Type(s) of exercise:
Bicycling
Running
Swimming
Walking
Aerobics
Other
times per week:
0
occasionally
1-2
3-4
5-6
7 or more
How would you describe your diet (mark all that apply)?
Low fat
Low salt
Low carbohydrate
Well balanced
Unhealthy
Limited junk food
Frequent junk food
Gluten free
Vegan
Advance Directive
Have you completed any of the following Advance Directives?
Living will
Durable power of attorney
POLST
None
Would you like the opportunity to discuss your end of life decisions or Advance Directives with your provider?
Yes
No
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 1201
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