Patient Information

*Please provide the patient's name as it appears on their driver's license, state identification card, or government issued identification card.

Patient History

* Required Information

Social History

Tobacco Use

*What is your smoking status?
*What age did you begin smoking?
*What age did you quit?
*How many cigarettes do you currently 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

*Do you drink alcohol?

Drug Use

*Do you have a history of substance abuse?
*Which substances?


*How often do you exercise?
Which type(s)?


*What is your marital status?
*What is your employment status?
*How many children do you have?
*What is your student status?
*Do you live alone?
*Are you on a special diet?

Past Medical History

*Please select all that apply.

Surgical History

Please select all that apply.

Family History

Please select all that apply.
Heart disease
High Blood Pressure
Difficulty with anesthesia
No Significant Medical History

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 287
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.