Patient Information (Full Legal Name)

Tobacco Use

What is your current cigarette smoking status?
At what age did you begin smoking?
If you quit smoking, at what age did you quit?
How many cigarettes do you smoke per day? How many cigarettes did you previously smoke per day?
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?


type(s) of caffeine:
drinks per day:

type(s) of exercise:
times per week:

Do you consume marijuana? (mark all that apply)
At what age did you begin using marijuana?
How often do you consume marijuana (now or in the past)?
If the frequency options do not apply, please explain.

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:

Alcohol Abuse


Anesthetic Complication



Bladder Problems

Bleeding Disease

Breast Cancer

Colon Cancer

Crohn's Disease



Heart Disease


High Blood Pressure

High Cholesterol

Kidney Disease

Liver Disease

Lung / Respiratory Disease



Rectal Cancer

Seizures / Convulsions

Severe Allergy

Stroke / CVA of the Brain

Thyroid Problems

Ulcerative Colitis

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 899
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.