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?
 
 
 
 
 
 
 
 
 
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:

 
 
 
 
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.