Tobacco Use (for ages 13 and older only)

How would you describe your cigarette smoking?
 
 
 
 
 
 
 
 
Have you tried quitting / been counseled to quit smoking?
 
 

Alcohol Use

How often do you use alcohol?
 
 
 
 
 
 
 
 
 
per
 
 
 
 

Habits

Do you use recreational drugs?
 
 
 
 
 
 
Exercise
 
 
 
 
 
Amount:
 
 
 
 
 
Type:
 
 
 
 
other (please specify):
 
 
 
 
 
 
Caffeine intake
 
Type:
 
 
 
 
Drinks per day:
 
 
 
 
 
 
 
 

YOUR Medical History

Please indicate if YOU have a history of the following:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

FAMILY Medical History

Please indicate if YOUR FAMILY has a history of the following:

 
 
 
Alcohol Abuse
 
 
 
 
 
Anemia
 
 
 
 
 
Anesthetic Complication
 
 
 
 
 
Arthritis
 
 
 
 
 
Asthma
 
 
 
 
 
Bladder Problems
 
 
 
 
 
Bleeding Disease
 
 
 
 
 
Breast Cancer
 
 
 
 
 
Colon Cancer
 
 
 
 
 
Depresson
 
 
 
 
 
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
 
 
 
 
 
 
 

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 889
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.