Personal / Family History

Do you have children?
How many children do you have?
Occupation:
Allergy History
Do you have any allergy history?
Past Medical History
Do you have any past medical history?
Family Medical History
Do you have any family medical history?
Alcohol Abuse
Anemia
Anesthetic Complication
Anxiety
Arthritis
Asthma
Bladder Problems
Bleeding Disease
Breast Cancer
Colon Cancer
Depression
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Lung / Respiratory Disease
Migraines
Osteoporosis
Rectal Cancer
Seizures / Convulsions
Severe Allergy
Stroke / CVA of the Brain
Thyroid Problems
Other Cancer
Surgical History
Do you have any surgical history?
Prostate Surgery
Gallbladder Surgery
Colon Polyp Removal
Colon Removal
Hysterectomy (due to cancer)
Hysterectomy (not due to cancer)
Spinal Fusion
Spinal Decompression
Dilation and Curettage (D&C)
Lung Surgery
Kidney Removal
Cataract Surgery
Breast Cancer Lump Removal
Mastectomy
Breast Reconstruction
Breast Reduction
Ovary Removal
Carpal Tunnel Surgery
Rotator Cuff Repair
Arthroscopic Shoulder Surgery
Hip Fracture & Surgery
Total Hip Replacement
Total Knee Replacement
Arthroscopic Knee Surgery
Foot Surgery
Varicose Vein Procedure
Mastoidectomy
Thyroid Removal
Breast Biopsy
Carotid Artery Surgery
Open Inguinal Hernia Surgery
Laparoscopic Inguinal Hernia Surgery
Caesarean Section
Heart Valve Replacement
Heart Bypass Surgery
Social History
Tobacco Use
What is your smoking history?
How many years did you smoke?
What was your daily use (i.e. number of cigarettes per day)?
What is your daily use (i.e. number of cigarettes per day)?
How many years have you been smoking?
Do you use e-cigarettes/vape?
Alcohol Use
How often do you use alcohol?
Per:
What type(s) of alcohol do you drink?
How many drinks do you have per occasion?
How often do you have more than five drinks per occasion?
Drug Use
Habits
Caffeine
type(s) of caffeine:
drinks per day:
Exercise
type(s) of exercise:
times per week:
How would you describe your diet (mark all that apply)?
Advance Directive
Have you completed any of the following Advance Directives?
Would you like the opportunity to discuss your end of life decisions or Advance Directives with your provider?
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 1201
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