Tobacco Use

What is your current cigarette smoking status?
At what age did you begin smoking?
How many cigarettes do you currently smoke or did you previously smoker per day?
If you quit smoking, at what age did you quit?
How many cigars or pipes do you smoke per week?
How many cans of smokeless / chewing tobacco do you use per week?
Are you exposed to passive (second hand) smoke?

Alcohol Use

How often do you use alcohol?
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


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.)


drinks per day:
type(s) of caffeine:

times per week:
type(s) of exercise:

How often do you wear a seatbelt?

Sun Exposure

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: (ONLY include parents, grandparetns, siblings, and children)


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 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.