Patient Information (Full Legal Name)
 
 
 
 
 
 
 
 
 
 
 

TOBACCO USE

What is your current cigarette smoking status?
 
 
 
 
 
 
How many packs per day do you smoke?
How many packs per day did you smoke?
 
 
How many years have you been smoking?
How many years did you smoke?
 
Do any of these statements apply to you?
 
 
 
 
Please mark any tobacco products that you use:
 
 
 
 
 
Are you exposed to secondhand smoke?
 
 
 
 
 

ALCOHOL USE

How often do you drink alcohol?
 
 
 
 
 
 
 
Type(s):
 
 
 
 

DRUG USE

How often do you use illicit drugs?
 
 
 
 
 
 
 
 
 
 
Type(s):
 
 
 
 
 
 
 
 

CAFFEINE USE

Do you consume any of these?
 
 
 
 
Servings per day:
 

EXERCISE

Number of times you exercise each week:
 
Type(s):
 
 
 
 
 
 
 
 
 
 

SEATBELT USE

 
 
 
 
 

Past Medical History

Please indicate if YOU have a history of the following:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Family Medical History

Please indicate which family members have had these illnesses:

 
 
 
 
Alcohol Abuse
 
 
 
 
 
 
 
Anemia
 
 
 
 
 
 
 
Anesthetic Complication
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 

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 870
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.