Personal/Family History
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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
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Personal / Family History
* Required Information
Social History
*
Smoking:
Current (every day)
Current (some days)
In the past
Never
*
Secondhand smoke exposure:
Yes
No
*
Alcohol:
Never
2-4
times per week
Daily
Rarely
*
Recreational drugs:
Never
Previous
Current
Prefer to discuss with physician
Past Medical History
Please indicate if
you
have had any of the following.
*
Mark all that apply.
Acid reflux / GERD
Anxiety
Arthritis
Asthma
Atrial fibrilation
Back pain
Blood clots in legs
Breast mass
CPAP use
Crohn's disease
Depression
Diabetes
Diverticulosis
Emphysema / COPD
Gallstones
Heart attack
Heart failure
Heart murmur
Hemorrhoids
Hepatitis
Hernia
High blood pressure
High cholesterol
History of blood transfusions
HIV positive
Home oxygen use
Kidney failure
Kidney stones
Migraines
Pancreatitis
Problems with anesthesia
Pulmonary embolism
Seizures
Sickle cell disease
Sleep apnea
Stomach ulcer
Stroke / TIA
High thyroid / Hyperthyroidism
Low thyroid / Hypothyroidism
Ulcerative colitis
Varicose veins
Enlarged prostate
Other significant medical illness:
None
Cancer
Breast
Colon
Lung
Melanoma / Skin
Ovarian
Pancreatic
Prostate
Thyroid
Other
Surgical History
Please indicate if
you
have had any of the following surgeries.
*
Mark all that apply.
I have had no surgeries
Angioplasty
Aortic aneurysm stent / repair
Appendix
Breast biopsy
Breast cancer lumpectomy
Breast implant(s)
C-Section
Cardiac stent placement
Carotid artery
Colon surgery
Colonoscopy
Coronary artery bypass surgery (CABG)
Thyroid
EGD (scope of the stomach)
Gallbladder removal
Gastric bypass
Heart valve surgery
Hemorrhoid treatment
Hernia
Hip surgery
Hysterectomy
Knee replacement
Lap band surgery
Liver biopsy
Mastectomy
Organ transplant
Pacemaker placement
Parathyroid
Plates / Screws for fracture
Prostate surgery
Removal of ovary(ies)
Skin cancer removal
Stomach ulcer surgery
Tubal ligation
Other surgery not listed above:
Family Medical History
Please indicate which family members have had these illnesses:
*
Mark all that apply.
Family history unknown
No significant family history
Bleeding disorder
Mother
Father
Sister
Brother
Daughter
Son
Colon polyps
Mother
Father
Sister
Brother
Daughter
Son
Crohn's disease
Mother
Father
Sister
Brother
Daughter
Son
Diabetes
Mother
Father
Sister
Brother
Daughter
Son
Genetic / Inheritable disease(s)
Mother
Father
Sister
Brother
Daughter
Son
Heart disease
Mother
Father
Sister
Brother
Daughter
Son
Problems with anesthesia
Mother
Father
Sister
Brother
Daughter
Son
Sickle cell disease
Mother
Father
Sister
Brother
Daughter
Son
Stroke
Mother
Father
Sister
Brother
Daughter
Son
Ulcerative colitis
Mother
Father
Sister
Brother
Daughter
Son
Breast cancer
Mother
Father
Sister
Brother
Daughter
Son
Colon cancer
Mother
Father
Sister
Brother
Daughter
Son
Lung cancer
Mother
Father
Sister
Brother
Daughter
Son
Melanoma / Skin cancer
Mother
Father
Sister
Brother
Daughter
Son
Ovarian cancer
Mother
Sister
Daughter
Pancreatic cancer
Mother
Father
Sister
Brother
Daughter
Son
Prostate cancer
Father
Brother
Son
Thyroid cancer
Mother
Father
Sister
Brother
Daughter
Son
Other cancer
Mother
Father
Sister
Brother
Daughter
Son
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 854
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.