Personal/Family History
After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
Robert F. Thompson M.D.
Mark S. Walton M.D.
Steven F Ellis M.D.
Mitchell J. Challis M.D.
Carson Williams M.D.
My provider is not in the list
---------- Date of Birth ----------
First Name
Last Name
Month
Day
Year
Gender
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Male
Female
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
Tobacco Use
What is your current cigarette smoking status?
current
(every day)
current
(some days)
previous
never
At what age did you begin smoking?
1
2
3
4
5
6
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99
How many cigarettes do you currently smoke or did you previously smoker per day?
1
2
3
4
5
6
7
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9
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If you quit smoking, at what age did you quit?
1
2
3
4
5
6
7
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9
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99
How many cigars or pipes do you smoke per week?
0
<1
1-2
3-5
6-9
10+
How many cans of smokeless / chewing tobacco do you use per week?
0
<1/2
1/2
1
2
3+
Are you exposed to passive (second hand) smoke?
yes
no
Alcohol Use
How often do you use alcohol?
never
1
2
3
4
5
6
7+
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+
How often do you have more than five drinks per occasion?
never
occaionally
rarely
frequently
Drug Use
none
current
previous
prefer to discuss with physician
HIV High Risk Behavior
(HIV Risk Factors: IV drug use, More than one sexual partner, Sex with a prostitute, Unprotected sexual contact, Contact with contaminated injection equipment.)
yes
no
prefer to discuss with physician
Habits
Caffeine
drinks per day:
0
occasionally
1-2
3-4
5-6
7+
type(s) of caffeine:
coffee
tea
soft drinks
Exercise
times per week:
0
occasionally
1-2
3-4
5-6
7+
type(s) of exercise:
bicycling
running
swimming
walking
aerobics
other
How often do you wear a seatbelt?
always
almost always
occasionally
never
Sun Exposure
rarely
occasionally
frequently
YOUR Medical History
Please indicate if YOU have a history of the following:
Alcohol Abuse
Anemia
Anesthetic Complication
Anxiety Disorder
Arthritis
Asthma
Autoimmune Problems
Birth Defect(s)
Bladder Problems
Bleeding Disease
Blood Clots
Blood Transfusion(s)
Bowel Disease
Breast Cancer
Cervical Cancer
Colon Cancer
Depression
Diabetes
Growth / Development Disorder
Heart Attack
Heart Disease
Heart Pain / Angina
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
High Cholesterol
HIV
Hives
Kidney Disease
Liver Cancer
Liver Disease
Lung Cancer
Lung / Respiratory Disease
Mental Illness
Migraines
Osteoporosis
Prostate Cancer
Rectal Cancer
Reflux / GERD
Seizures / Convulsions
Severe Allergy
Sexually Transmitted Disease (STD)
Skin Cancer
Stroke / CVA of the Brain
Suicide Attempt
Thyroid Problems
Ulcer
Other Disease, Cancer, or Significant Medical Illness
NONE of the Above
FAMILY Medical History
Please indicate if YOUR FAMILY has a history of the following: (ONLY include parents, grandparetns, siblings, and children)
Family History Unknown
No Pertinent Family History
Alcohol Abuse
Anemia
Anesthetic Complication
Arhtritis
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
Mother, Grandmother, or Sister developed Heart Disease before age 65.
Father, Grandfather, or Brother developed Heart Disease before age 55.
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 20
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.