Patient / Family History
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Patient Information
*
Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
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Birth Year
2022
2021
2020
2019
2018
2017
2016
2015
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2013
2012
2011
2010
2009
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1911
1910
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1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
* Required Information
Patient / Family History
Tobacco Use
*
What is your smoking status?
Current (every day)
Current (some days)
Previous
Never
How many cigarettes per day?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Alcohol Use
*
How often do you use alcohol?
Never
Once a month
2-3 times per week
Once a week
Nearly every day
*
About how much do you drink on each occasion?
1-2
3-5
6-9
10 or more
*
Drug Use
None
Currently use
Previous
Prefer to discuss with physician
Your Medical History
*
Do you have any medical history problems?
Yes
No
Anemia
Cancer
Kidney Failure
Anxiety / Depression
Diabetes
Kidney Stones
Arthritis
Heart Disease
Liver Disease
Asthma or Emphysema
Hepatitis
Migraine Headaches
Bladder Dysfunction
High Blood Pressure
Seizures
Blood Clotting Disorder
High Cholesterol
Stroke
Bowel Disease
HIV
Thyroid Problems
*
Family Medical History
Do you have any family medical conditions?
Yes
No
Arthritis
Heart Failure
Lupus Nephritis
Cancer
Hypertension
Osteoporosis
Diabetes
Kidney Failure
Stroke
Heart Attack
Liver Failure
*
Surgical History
Do you have any surgical history?
Yes
No
Hysterectomy (Ovaries Not Removed)
Hysterectomy (Ovaries Removed)
Aneurysm Repair
Heart Stent
Knee Surgery
Appendectomy
Heart Valve Surgery
Mastectomy
Back Surgery
Hernia
Nephrectomy
Bladder Surgery
Hip Replacement
Ovary(ies) Removed
Blood Transfusion
Hip Surgery
Pacemaker
C-section
Prostate Removal
Gallbladder Removed
Spleen Removal
Gastric Bypass
Kidney Biopsy
Thyroid Removal
Heart Bypass
Knee Replacement
Tonsils Removed
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 491
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