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?
 
 
 
 
 
 
 
 
Per:
 
 
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?
 
 
 
 
 

Habits

Caffeine
 
type(s) of caffeine:
 
 
 
drinks per day:
 
 
 
 
 

Exercise
 
type(s) of exercise:
 
 
 
 
 
 
times per week:
 
 
 
 
 

Marijuana
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:

 
 
Mother Father Sister Brother Daughter Son
Alcohol Abuse
Anemia
Anesthetic Complication
Arthritis
Asthma
Bladder Problems
Bleeding Disease
Breast Cancer
Colon Cancer
Crohn's Disease
Depression
Diabetes
Heart Disease
Hemochromatosis
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease
Lung / Respiratory Disease
Migraines
Osteoporosis
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.