Medical History
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Provider Name
Patient Information
*
Please provide your full legal name as it appears on your 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
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
Medical History
* Required Information
Tobacco
*
Have you
ever
smoked cigarettes (more than 5 packs in a lifetime)?
Yes
No
*
Do you smoke cigarettes
now
(as of 1 month ago)?
Yes
No
*
How many packs of cigarettes do you smoke per day?
½ or less
1
1½
2
3
3½
4 or more
*
How many packs of cigarettes did you smoke per day?
½ or less
1
1½
2
3
3½
4 or more
*
Do you
awaken
during the night to smoke?
Yes
No
*
How many years have you smoked? (Include past and present)
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36 or more
Alcohol
*
How often do you have a drink containing alcohol?
Never
Less than monthly
2-4 times / month
2-4 times / week
Daily
*
How many drinks containing alcohol do you have on a typical day when you are drinking?
1-2
3-4
5-6
7-8
9 or more
*
How often do you have six or more drinks containing alcohol?
Never
Less than monthly
2-4 times / month
2-4 times / week
Daily
Caffeine
Use the information given below to estimate the number of ounces.
Small cup = 5 oz, Regular or small mug / cup = 8 oz, Large mug = 12 oz, Regular can of soda / cola = 12 oz, Regular bottle of water = 20 oz
On a typical day, how many ounces of caffeinated coffee, tea, cola/soda do you drink?
*
Coffee
None
Less than 8 oz
8-16 oz
16-24 oz
24-48 oz
48-72 oz
More than 72 oz
*
Tea
None
Less than 8 oz
8-16 oz
16-24 oz
24-48 oz
48-72 oz
More than 72 oz
*
Colas/Sodas
None
Less than 8 oz
8-16 oz
16-24 oz
24-48 oz
48-72 oz
More than 72 oz
*
How often do you use pills containing caffeine (e.g. NoDoz®)?
Never
Less than monthly
2-4 times / month
2-4 times / week
Daily
Recreational Drug Use
*
Do you use any illegal drugs or substances (marijuana, cocaine, etc)?
Yes
No
*
Medical History
Fibromyalgia
Stomach ulcers
Seizures / Epilepsy
Trauma
Kidney failure
Stroke
Vision / Hearing loss
Kidney stones
Anxiety disorder
Chronic / Frequent sinusitis
Bladder problems
Bipolar disorder
Deviated septum
Urinary tract infections
Depression
Angina
Dialysis
History of psychiatric treatment
Coronary artery disease
Prostate problems
Diabetes
Pacemaker
Impotence / Erectile dysfunction
Anemia
Heart Attack
Gynecological problems
Clots in leg or lung
Heart defibrillator
Polycystic ovarian syndrome
Hepatitis
Heart failure
High cholesterol
Heart murmur
Poor leg circulation
High blood pressure
Thyroid disease
Irregular heart rhythm
Lung cancer
Asthma
Breast cancer
Chronic bronchitis
Colon cancer
Emphysema / COPD
Chronic / Intermittent back pain
Prostate cancer
Pneumonia
Osteoarthritis
Leukemia / Lymphoma
Acid reflux
Rheumatoid arthritis
Other cancer
Gall bladder disease
Gout
Hay fever
Pancreatitis
Headaches
Other medical problem
Hiatal hernia
Paralysis
Irritable bowel syndrome
Parkinson's disease
Arthritis in:
Hands
Hips
Knee
Shoulders
Spinal
No known medical problems
*
Surgical History
Appendectomy (appendix)
Eye / Cataract surgery
Ovaries removed
Breast surgery
Gastric bypass / Lap-band
Plastic surgery
Caesarean section
Hernia repair
Prostate surgery
Cardiac angioplasty / stent
Hysterectomy (uterus)
Sinus surgery
Cardiac bypass surgery
Jaw surgery
Throat surgery for snoring
Carotid surgery
Joint replacement
Tonsillectomy (tonsils)
Cholecystectomy (gallbladder)
Nasal surgery
Other surgery
Colon surgery
Orthopedic surgery
No surgeries
Family History
Sleep apnea found during a sleep study
Father
Mother
Brother
Sister
Child
Grandparent
Other
Narcolepsy
Father
Mother
Brother
Sister
Child
Grandparent
Other
Restless legs syndrome
Father
Mother
Brother
Sister
Child
Grandparent
Other
Heavy snoring
Father
Mother
Brother
Sister
Child
Grandparent
Other
Sleep walking / Sleep terrors
Father
Mother
Brother
Sister
Child
Grandparent
Other
Insomnia
Father
Mother
Brother
Sister
Child
Grandparent
Other
Diabetes
Father
Mother
Brother
Sister
Child
Grandparent
Other
High blood pressure
Father
Mother
Brother
Sister
Child
Grandparent
Other
Congenital heart disease
Father
Mother
Brother
Sister
Child
Grandparent
Other
Coronary heart disease
Father
Mother
Brother
Sister
Child
Grandparent
Other
Thyroid disease
Father
Mother
Brother
Sister
Child
Grandparent
Other
Stroke
Father
Mother
Brother
Sister
Child
Grandparent
Other
Seizures
Father
Mother
Brother
Sister
Child
Grandparent
Other
Abnormal heart rhythm
Father
Mother
Brother
Sister
Child
Grandparent
Other
Neurologic disorders
Father
Mother
Brother
Sister
Child
Grandparent
Other
Cancer
Father
Mother
Brother
Sister
Child
Grandparent
Other
Developed heart disease before age 60?
Father
Mother
Brother
Sister
Child
Grandparent
Other
Psychiatric illness
Father
Mother
Brother
Sister
Child
Grandparent
Other
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 212
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.