Medical History Social History Cigarettes Pkg per day:______ #Years Smoking:______ Year Quit Smoking:______ □ Alcohol Drinks per week:______ □ Coffee Cups per day:______ □ Exercise Yes No □ □ □ Sleep Pattern # Hours per night:______ Satisfactory Occasionally Disturbed Mostly Disturbed □ □ □ □ Street Drugs Yes No □ □ □ Current Concerns or any Additional Information
Medical History Social History □ Cigarettes Pkg per day:______ #Years Smoking:______ Year Quit Smoking:______ □ Alcohol Drinks per week:______ □ Coffee Cups per day:______ □ Exercise □ Yes □ No □ Sleep Pattern # Hours per night:______ □ Satisfactory □ Occasionally Disturbed □ Mostly Disturbed □ Street Drugs □ Yes □ No Current Concerns or any Additional Information