Patient History
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Provider Name
Patient Information
Informaci�n del paciente
*
Please provide the patient's 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
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25
26
27
28
29
30
31
Birth Year
2023
2022
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
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1975
1974
1973
1972
1971
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1969
1968
1967
1966
1965
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1963
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1961
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1956
1955
1954
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1950
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1946
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1942
1941
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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
Patient History
* Required Information
Social History
Tobacco Use
*
What is your smoking status?
Current (every day)
Current (some days)
Previous
Never
*
What age did you begin smoking?
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
32
33
34
35
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37
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39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
*
What age did you quit?
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
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
*
How many cigarettes do you currently smoke per day?
*
How many cigarettes did you previously smoke per day?
1
2
3
4
5
6
7
8
9
10 (½ pack)
11
12
13
14
15
16
17
18
19
20 (1 pack)
21
22
23
24
25
26
27
28
29
30 (1½ packs)
31
32
33
34
35
36
37
38
39
40 (2 packs)
41
42
43
44
45
46
47
48
49
50 (2½ packs)
51
52
53
54
55
56
57
58
59
60 (3 packs)
61
62
63
64
65
66
67
68
69
70 (3½ packs)
71
72
73
74
75
76
77
78
79
80 (4 packs)
81
82
83
84
85
86
87
88
89
90 (4½ packs)
91
92
93
94
95
96
97
98
99
*
How many cigars or pipes do you smoke per week?
None
<1
1-2
3-5
6-9
10+
*
How many cans of smokeless/chewing tobacco do you use per week?
None
<½
½
1
2
3+
*
Are you exposed to passive (second hand) smoke?
Yes
No
Alcohol Use
*
Do you drink alcohol?
No
Yes, 1-2 times per week
Yes, 1-2 times per month
Yes, 1-2 times per year
Drug Use
*
Do you have a history of substance abuse?
Yes
No
*
Which substances?
Meth
Prescriptions not prescribed to me
Cocaine
Prescription medications
Heroin
Marijuana
Other
Exercise
*
How often do you exercise?
Daily
Weekly
Monthly
Rarely
Never
Which type(s)?
Aerobics
Walking
Swimming
Bicycling
Running
Other
Other
*
What is your marital status?
Single
Partnered
Divorced
Married
Separated
Widowed
*
What is your employment status?
Part-time
Active duty
Retired
Full-time
Self employed
Disabled
Not employed
*
How many children do you have?
0
1
2
3
4
5
6
7
8
9
10
11 or more
*
What is your student status?
Full-time
Part-time
Not a student
*
Do you live alone?
No
Yes
*
Are you on a special diet?
No
Yes
Past Medical History
*
Please select all that apply.
Epilepsy
Heart disease
HIV
High blood pressure
Hepatitis
Cancer
Tuberculosis
Arthritis
Anesthesia problems
Polio
Diabetes
Other
None
Surgical History
Please select all that apply.
Arthroscopic shoulder surgery
Arthroscopic knee surgery
Open shoulder surgery
Open knee surgery
Other orthopaedic surgery
I have had no surgeries
Family History
Please select all that apply.
Family history unknown
Diabetes
Father
Mother
Brother
Sister
Son
Daughter
Heart disease
Father
Mother
Brother
Sister
Son
Daughter
Arthritis
Father
Mother
Brother
Sister
Son
Daughter
High Blood Pressure
Father
Mother
Brother
Sister
Son
Daughter
Difficulty with anesthesia
Father
Mother
Brother
Sister
Son
Daughter
No Significant Medical History
Father
Mother
Brother
Sister
Son
Daughter
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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.