Patient Information

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
 
 
 

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?
 
 
 
 
 
 
 

Exercise

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

Other

 
 
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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Surgical History

 
 
 
 
 
 
 
 

Family History

 
 
 
 
Diabetes
 
 
 
 
 
 
 
Heart Disease
 
 
 
 
 
 
 
Arthritis
 
 
 
 
 
 
 
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.