*Please provide the patient's full legal name as it appears on their 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?
How many cigars or pipes do you smoke per week?
How many cans of smokeless / chewing tobacco do you use per week?
Are you exposed to passive (secondhand) smoke?
How often do you use alcohol?
What type(s) of alcohol do you drink?
How many drinks do you have per occasion?
How often do you have more than five drinks per occasion?
(HIV Risk Factors: IV drug use, more than one sexual partner, sex with a prostitute, unprotected sexual contact, contact with contaminated injection equipment.)
How often do you wear a seatbelt?
*Do you have any medical history problems?
*Do you have any family medical conditions?
Lung / Respiratory disease
Stroke / CVA of the brain