Personal/Family History
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In order to notify the clinic, please enter your name and other demographic information above and enter the name
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Provider Name
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
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Birth Day
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Birth Year
2022
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1911
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1904
1903
1902
1901
1900
Gender
Male
Female
Personal/ Family History
* Required Information
Tobacco Use
*
How would you describe your cigarette smoking?
Current (everyday)
Current (some days)
Previous
Never
How many years have you smoked?
How many years did you smoke?
<1
1
2
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5
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99
How many cigarettes do you currently smoke per day?
How many cigarettes did you previously smoke per day?
1 pack
2 packs
More than 2 packs
*
Do you or have you used any other form of tobacco?
Yes
No
Alcohol Use
*
Do you drink alcohol?
Never
Occasionally
Often
*
Illegal / Illicit Drug Use
None
Current
Previous
Prefer to discuss with physician
*
Are you concerned about HIV Risk?
Yes
No
*
Allergies
Please mark any known allergies you have.
No drug allergies
Demerol
Codeine
Latex
IV Contrast Material / Iodine
Anesthesia
Penicillin
Morphine
Other
Please describe your reaction:
*
Your Medical History
Please indicate if YOU have a history of the following:
Anemia
High cholesterol / hyper lipidemia
Anxiety disorder
HIV
Arthritis
Kidney disease
Asthma
Liver disease
Back pain requiring narcotics
Lung cancer
Bleeding disease
Lung / respiratory disease
Blood clots
Neuropathy
Blood transfusion(s)
Mental illness
Bowel disease
Migraines
Breast cancer
Obesity
Cardiovascular disease
Osteoporosis
Chronic use of narcotics / Pain relievers
Peripheral vascular disease
Cirrhosis
Prostate cancer
Colon cancer
Rectal cancer
Coronary disease
Reflux / GERD
Depression
Restless leg syndrome
Diabetes
Seizures / convulsions
Fibromyalgia
Skin cancer
Heart pain / angina
Stroke / CVA of the brain
Hepatitis B
Suicide attempt
Hepatitis C
Thyroid problems
High blood pressure
Venous insufficiency
Other Disease, cancer, or significant medical illness
Please list any additional conditions or diseases you have had (not shown above):
None of the above
*
Family Medical History
Please indicate if YOUR FAMILY has a history of the following: ONLY include parents, grandparents, siblings, and children
Family history unknown
None
Alcohol abuse
High blood pressure
Anesthetic complication
High cholesterol
Aneurysm
Kidney disease
Asthma
Lung / respiratory disease
Bleeding disease
Other cancer
Breast cancer
Seizures / convulsions
Colon cancer
Severe allergy
Diabetes
Stroke / CVA of the brain
Heart disease
Vascular disease
Please list any family members with history of Cancer:
Please list any additional pertinent family medical history (not shown above):
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 216
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.