Do you smoke? a day ____ Years _____ YES NO Packs Are you a past smoker? YES □ □ □ □ NO Do you drink? If yes, how often? Rarely Moderately Daily Quit YES NO □ □ □ □ □ □
Do you smoke? □ YES □ NO Packs a day ____ Years _____ Are you a past smoker? □ YES □ NO Do you drink? □ YES □ NO If yes, how often? □ Rarely □ Moderately □ Daily □ Quit
4.-Health-History.docx