*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
What is your smoking status?
At what age did you begin smoking?
At what age did you quit?
How many cigarettes do you currently smoke per day?
How many cigarettes did you previously smoke per day?
Are you exposed to passive (secondhand) smoke?
HIV High Risk Behavior
(HIV Risk Factors: IV drug use, more than one sexual partner, sex with a prostitute, unprotected sexual contact, contact with contaminated injection equipment.)
drinks per day:
Past Medical History
Do you have any medical history problems?
Family Medical History
Do you have any family medical conditions?